Dr.  J.  R.  Brown, 
909  Wylie  Ave., 

Pittsburg,  Pa. 


THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 

Gift  of 
Mrs.  Lottie  Brown 


A  TREATISE 

OX   THK 

ACUTE,   INFECTIOUS 
I       EXANTHEMATA 


INCLUDING 


VARIOLA,  RUBEOLA,  SCARLATINA,  RUBELLA,  VARICELLA, 

AND  VACCINIA,  WITH  ESPECIAL  REFERENCE 

TO  DIAGNOSIS  AND  TREATMENT 


BY 


WILLIAM  THOMASCORLETT,  M.D.,  LR.C.P.Lond., 


PROFESSOR  of   DERMATOLOGY  AND  SYPIIILOLOGY  IN  WESTERN   RKSKHVK  UNIVERSITY;    PHYSICIAN   FOR  DIS- 

EASES OF  THK  SKIN  TO  LAKESIDE  HOSPITAL  :  CONSULTING  DERMATOLOGIST  TO  CHARITY  HOSPITAL, 

ST.  ALEXIS  HOSPITAL.  AND  THE  CITY  HOSPITAL,  CLEVELAND;  MEMBKR  OF  THE 

AMERICAN  OERMATOLOGICAL  ASSOCIATION  AND  THE  DEKMATOLOG- 

ICAL  SOCIETY  OF  GREAT  BRITAIN  AND  IRELAND. 


Illustrated  by  12  Colored   Plates,   28  Half-tone  Plates 
from  Iiife,   and   2  Engravings 


PHILADELPHIA 

F.  A.   DAVIS  COMPANY,  PUBLISHERS 
1901 


COPYRIGHT,  1901, 

BT 
F.  A.  DAVIS  COMPANY. 

[Registered  at  Stationers'  Hall,  London,  Eng. 


Philadelphia,  Pa..  U.  8.  A. 

Tb*  Medical  Bulletin  Printing-houM. 

1916  Cherry  Street. 


Biomedicai 
Ubrary 


570 


PREFACE. 


THE  present  volume  is  the  outgrowth  of  a  need  for  such  a  work 
felt  by  the  author  when  young  in  the  practice  of  medicine.  A  keen 
recollection  of  the  difficulties — not  to  mention  the  discomfiture — in 
encountering  the  acute  exanthemata  has  prompted  him  during  sub- 
sequent years  of  clinical  teaching  to  give  special  prominence  to  the 
differential  diagnosis,  and,  when  possible,  bedside  instruction  in  this 
class  of  affections. 

The  obstacles  in  the  way  of  broad  clinical  study  and  bedside 
demonstration  in  such  dangerous  and  highly  communicable  diseases 
as  variola,  scarlatina,  and  rubeola  render  it  hazardous  and  in  many 
instances  impracticable  to  impart  sufficient  instruction  to  under- 
graduates. This  fact,  together  with  the  limited  number  of  special 
hospitals  and  wards  for  the  reception  of  the  acute  exanthemata  at 
the  disposal  of  many  clinical  teachers,  makes  even  graduate  instruc- 
tion in  this  subject  one  of  the  most  difficult  departments  of  medicine 
in  which  it  is  possible  to  obtain  a  sufficient  degree  of  familiarity. 

The  truthfulness  in  detail  of  photographic  reproductions,  and 
the  gratifying  reception  accorded  the  author's  lantern-slide  demon- 
strations of  the  acute  exanthemata,  have  suggested  to  him  that  the 
time  is  opportune  for  a  separate  work  on  this  most  important  group 
of  diseases.  The  work  is  designed  to  be  practical  and  to  present  the 
subject  in  the  light  of  modern  research.  To  further  enhance  its  use- 
fulness, and  in  order  to  reproduce  in  color  certain  negatives  requiring 
special  demonstration,  the  .services  of  Felix  Meheux,  dessinateur  et 
photographe  of  the  Hopital  Saint-Louis,  Paris,  have  been  secured, 
whose  life-like  illustrations  in  Chatelain's  admirable  work  on  diseases 
of  the  skin  have  sufficiently  introduced  him  to  the  medical  profession. 
In  this  way  the  most  delicate  shades  of  color  have  been  given,  not 
only  as  peculiar  to  the  particular  diseases,  but,  when  thought  desir- 
able, the  various  stages  through  which  they  pass  have  been  illustrated 
in  color,  as  well  as  the  conditions  most  liable  to  mask  their  appearance. 
The  illustrations,  with  the  exceptions  of  Plates  I,  X,  XXIV,  XXVII, 
XXVIII,  XXXIII,  and  XXXIV,  are  reproduced  from  photographic 
negatives  taken  by  the  author. 


707009 


iv  PREFACE. 

It  has  been  the  endeavor  to  render  the  text  as  complete  as  is 
consistent  with  brevity,  and  at  the  same  time  to  give  a  clear  exposi- 
tion of  the  subject. 

In  the  chapter  devoted  to  the  early  history  of  the  exanthemata 
the  author  desires  to  express  his  appreciation  of  the  kind  and  pains- 
taking services  given  him  by  Dr.  Henry  E.  Handerson,  of  Cleveland, 
and  of  the  courtesy  extended  by  the  Librarian  of  the  Surgeon-Gen- 
eral's Library  at  Washington  for  the  use  of  valuable  works  on  the 
subjects  treated  of.  The  author  is  further  indebted  to  numerous 
recent  writers  of  this  and  foreign  countries  whose  works  have  been 
freely  consulted  and  to  whom  he  hopes  due  credit  has  in  every  instance 
been  given.  For  all  inadvertent  omissions  in  this  direction  he  asks 
indulgence. 

He  further  desires  to  thus  publicly  acknowledge  his  obligation 
for  the  universal  courtesy  extended  him  by  his  colleagues  in  calling 
his  attention  to  unusual  and  interesting  cases,  as  well  as  for  the  per- 
mission to  photograph  such  as  were  required. 

In  conclusion  he  wishes  to  express  his  appreciation  of  the  assist- 
ance given  him  by  Dr.  Edward  Perkins  Carter,  Clinical  Assistant  in 
Dermatology  at  the  Lakeside  Hospital,  who  has  contributed  the  text 
for  the  chapter  on  scarlet  fever  and  has  assisted  in  the  preparation  of 
the  index. 

553  EUCLID  AVENUE,  CLEVELAND, 
APRIL  15,  1901. 


CONTENTS. 


PAGE 

PREFACE iii 

LlST    OF    Cl I. VIM'S    AND    DIAGRAMS vi 

LIST  OF  FULL-PAGE  PLATES.  .  vii 


CHAPTER  I. 
THE  EARLY  HISTORY  OF  THE  EXANTHEMATA 1 

CHAPTER  II. 
VARIOLA 28 

CHAPTER  III. 
VACCINIA   128 

CHAPTER  IV. 
VARICELLA 152 

CHAPTER  V. 
SCARLATINA  ' 169 

CHAPTER  VI. 
RUBEOLA 276 

CHAPTER  VII. 
RUBELLA  .  .   348 


ADDENDUM 373 

INDEX 387 

(v) 


LIST  OF  CHARTS  AND  DIAGRAMS. 


PAGE 

Chart  showing  High  Temperature  and  Marked  Secondary  Fever  in  a  Case 
of  Confluent  Small-pox  terminating  in  Recovery.  (From  One  of  the 
Author's  Patients.) 42 

Chart  showing  Temperature  in  a  Case  of  Varioloid.      (From  One  of  the 

Author's  Patients.) 55 

Chart  in  Varioloid,  showing  High  Prodromal  Fever,  followed  by  Subnormal 

Temperature.     (From  One  of  the  Author's  Patients.) 61 

Diagram  showing  the  Influence  of  the  Sheffield  Hospital  in  Spreading  the 

Disease  in  1887-88.     (Taken  from  J.  W.  Moore.) 83 

Diagram    showing    the    Influence    of    Wind    in    Disseminating    Small-pox. 

(Taken  from  J.  W.  Moore.) 84 

Chart  of  Scarlatina  Simplex.     Normal,  Uncomplicated  Course.      (Writer's 

Case.)     175 

Chart  of  Scarlatina  Septica.      (Writer's  Case.) 180 

Diagram  showing  the  Influence  of  the  Scarlet-Fever  Hospital  in  Distribut- 
ing the  Disease 230 

Chart  of  Severe  Case  of  Measles  ending  in  Recovery  without  Complica- 
tions    286 

Diagram  showing  the  Neglect  and  Enforcement  of  Isolation  and  Disinfec- 
tion of  Measles. .  .  339 


(vi) 


LIST  OF  FULL-PAGE  PLATES. 


PAGE 

PLATE'  I. — A  Religious  Dramatic  Representation  of  the  Power  of  the 
Hindoo  Goddess  of  the  Small-pox.  (From  an  Ancient  Oriental 
Drawing.)  Facing  3 

PLATE  II. — Variola,  showing  Hard  Papular  Eruption  on  the  Morning  of 

the  Second  Day Facing       36 

PLATE  III. — Variola  in  the  Negro:    Papular  Stage  as  Seen  Late  on  Second 

Day  of  Eruption Facing      36 

PLATE  IV.— Variola,  on  the  Fifth  Day  of  the  Eruption,  showing  Marked 
(Edema,  Erysipelatous  Redness,  and  the  Transition  of  Vesicles  into 
Pustules.  Lesions  having  a  Dark  Central  Depression  have  been 
Opened.  Plate  II  Represents  the  same  Case  Taken  Three  days 
Earlier.  (Colored.) Facing  36 

PLATE  V. — Variola  in  Xegro :    Seventh  Day  of  Eruption Facing       38 

PLATE  VI. — Small-pox  Eruption  on  Arm,  showing  Full  Development  of 
Lesions,  Some  of  which  are  Umbilicated.  Eighth  Day  of  Eruption 
and  Twelfth  of  Disease Facing  38 

PLATE  VII. — Variola,  Bullous  Form,  resembling  Impetigo Facing       40 

PLATE  VIII. — Variola  (Confluent),  showing  Erysipelatous  Redness,  with 

Indurated  Papules,  Third  Day  of  the  Eruption.     (Colored.) .  .Facing      40 

PLATE  IX. — Confluent   Small-pox,   Same   as   Preceding,   showing  Lesions 

on  Hand  and  Forearm  the  Day  Following Facing      42 

PLATE  X. — Confluent  Small-pox:     Early  Pustular  Stage.      (Through  the 

Courtesy  of  Dr.  J.  F.  Schamberg. ) Facing      42 

PLATE  XI. — Variola,  showing  Mature  Pustules  on  the  Eighth  Day  of  the 
Eruption,  Confluent  on  Exposed  Surfaces,  Discrete  on  the  Trunk. 
(Colored. )  Facing  44 

PLATE  XII. — Confluent  Small-pox  in  Child  Six  Weeks  Old.  Mucous  Mem- 
brane of  the  Mouth  Extensively  Involved,  Ending  in  Recovery. 

Facing      44 

PLATE  XIII. — Variola,  showing  Desiccation  well  Advanced  on  the  Face, 
a  few  Blackish  Crusts  Remaining;  Desiccation  not  yet  Extended 
to  the  Extremities;  Twelfth  Day  of  the  Eruption.  Case  Same  as 
in  Plate  XL  (Colored.) Facing  46 

PLATE  XIV. — Variola,  Same  as  Preceding,  showing  Feet,  which  Present 

Later   Stage   of   Eruption Facing      46 

PLATE  XV.— Variola:  Confluent  on  Face,  Semiconfluent  and  Discrete  on 
Other  Parts  of  the  Body.  Mucous  Membranes  of  Mouth  and  Throat 
Covered  with  Well-Formed  Pustules Facing  46 

PLATE  XVI. — Variola,    showing   Stage   of   Decrustation   well   Advanced. 

Patient  same  as  in  Plates  XI,  XIII,  and  XIV Facing      46 

PLATE  XVII. — Same  as  in  Plate  XV  After  Recovery,  showing  Permanent 

Scarification  ot  the   Skin Facing      48 

PLATE  XVIII. — Corymbose  Small-pox,  showing  a  Cluster  of  Lesions  on 

Forearm    Facing      48 

(vii) 


Viii  LIST   OF   FULL-PAGE    PLATES. 

PAGK 

PLATE  XIX.— Varioloid,  presenting  Multiform  Lesions  resembling  a  Syph- 

iloderma  or  Varicella Facing  ~>S 

PLATE  XX.— Varioloid,  Posterior  View  of  the  Preceding..  ..Facing      58 

PLATE  XXI.— Bullous  Eruption  following  Vaccination..  ..Facing     140 

PLATE  XXII.— Same  as  the  Preceding,  showing  Feet  and  Ankles.  .Facing     140 

PLATE  XXIII.— Vaccination  in  a  Patient  Recently  Infected  with  Syph- 
ilis, showing  a  Generalized  Macular  Syphilide  and  an  Ulcerated 
Vaccinal  Lesion,  with  Local  Secondary  Pus  Infection.  (Colored.) 

Facing  144 

PLATE  XXIV. — "The  Cow-pox,  or  the  Wonderful  Effects  of  the  New 
Inoculation."  Distributed  by  the  Antivaccine  Society  of  London. 
(From  an  Old  Print  in  the  Author's  Collection.) Facing  14S 

PLATE  XXV .—Varicella,  showing  Typical  Distribution,  with  Areola  well 

Marked  Facing  158 

PLATE  XXVI. — Varicella,  showing  Contour  of  the  Lesions,  with  Areola. 

Facing  158 

PLATE  XXVII. — Varicella  resembling  Variola.  (Through  the  Courtesy 

of  Dr.  H.  H.  Powell.)  (Colored.) Facing  100 

PLATE  XXVIII. — Varicella,  showing  Posterior  View  of  One  in  the  Pre- 
ceding. (Colored.) Facing  ItiO 

PLATE  XXIX. — Varicella  resembling  Varioloid Facing     It'.O 

PLATE  XXX. — Scarlatina,  showing  Eruption  at  its  Height,  with  "Straw- 
berry Tongue."  (Colored.) Facing  1 7S 

PLATE  XXXI. — Scarlatina,  showing  Eruption  on  the  Legs Facing     178 

PLATE  XXXII. — Scarlatina,  showing  Desquamation.  (Through  the 

Courtesy  of  Dr.  J.  F.  Schamberg.) Facing  178 

PLATE  XXXIII.— Scarlatina  and  Varicella  Co-existing Facing     188 

PLATE  XXXIV. — The  Pathognomonic  Sign  of  Measles.  (Through  the 

Courtesy  of  Dr.  Koplik.)  (Colored.) Facing  280 

PLATE  XXXV. — Rubeola,  showing  the  Eruption  during  the  First  Day. 

Facing  284 

PLATE  XXXVI. — Rubeola,  Mild  Form,  showing  Clustering  of  Lesions  on 

Arms  Facing  288 

PLATE  XXXVII.— Rubeola,  showing  a  Typical  Eruption  on  the  Second 

Day  Facing  290 

PLATE  XXXVIII. — Rubeola,  Posterior  View  of  the  Preceding,  on  the 

Third  Day  of  the  Eruption Facing  2!)0 

PLATE  XXXIX. — Rubeola,  showing  Grouping  of  the  Lesions.  (Colored.) 

Facing  320 

PLATE  XL. — Rubeola,  the  Eruption  becoming  Confluent  on  the  Chest, 
resembling  Somewhat  the  Eruption  of  Scarlet  Fever.  (Colored.) 

Facing  320 

PLATE  XLL— Rubella,  showing  a  Typical  Eruption,  with  Enlargement 

of  the  Post-cervical  Lymphatic  Glands.  (Colored.) Facing  356 

PLATE  XLII. — Rubella,  showing  Well-MarKed  Eruption  at  its  Height  in 

the  Back Facing  358 


CHAPTEE   I. 

THE  EARLY  HISTORY  OF  THE  EXANTHEMATA. 

FBOII  its  striking  appearance  and  fatality  SMALL-POX  was  the  first 
of  the  exanthemata  to  be  recorded.  It  is  of  very  ancient  origin,  and 
comes  to  us  from  an  uncertain,  though  remote,  past.  In  the  Old 
Testament  there  is  nothing  we  can  positively  identify  as  the  affection 
unless  it  be  the  Egyptian  plague  (mE  P.ynyDN  jTHitf),  "Schechin 
Ababiioth  Poreach,"  which,  in  the  Septuagint  translation,  is  rendered 
"e3.y>7  p?;,i;yTi<5e$,"  and  in  Luther's  translation  into  German  is  ex- 
pressed as  Bosen  Schwarzen  Blattern  (Exodus  ix,  9).  Again,  it  is  ^in- 
fortunate  for  the  medical  historian  that,  among^  the  older  writers, 
pestilence  and  plague  are  sometimes  used  synonymously  with  small-pox 
and  other  eruptive  fevers.1  It  is  interesting  to  note,  however,  that 
wherever  small-pox  is  mentioned  it  is  never  spoken  of  as  a  new  or  un- 
heard-of affection,  which  leads  one  to  suppose  that  it  is  of  greater 
antiquity  than  the  oldest  records  show. 

China. — Some  of  the  most  ancient  written  records  are  found  in 
China,  and  to  them  we  naturally  turn  in  seeking  the  early  history 
of  this  disease.  From  the  favor  shown  to  medical  works  in  the  Royal 
Edict  (246  B.C.)2 — which  consigned  to  destruction  all  books  save  those 
pertaining  to  agriculture,  law,  and  physic — we  are  able  to  ascertain 
the  status  of  medicine  among  the  Chinese  centuries  before  the  advent 
of  European  civilization.  Thus,  from  the  Jesuit  missionaries  sent  to 
China,  who  became  familiar  with  the  customs,  literature,  and — to  a 
certain  extent — the  diseases  of  the  country,  we  are  enabled,  with  more 
or  less  accuracy,  to  establish  an  ancient  pedigree  for  many  diseases  of 
the  present  day.  From  them  we  learn  that  a  book,  published  by  the 
Imperial  College  of  Medicine  of  Peking  for  the  instruction  of  the  phy- 
sicians of  the  Empire,  entitled  "Tou-tchin-fa,"  or  "A  Treatise  from 
the  Heart  on  the  Small-pox,"  states  that  the  disease  was  unknown  in 
China  until  some  time  during  the  dynasty  of  Tcheou  (which  began  in 

1  In  the  first  Latin  translation  of  Rhazes  small-pox  was  called  Pestis,  and  Con- 
stantinus  Africanus  classed  it  among  the  Pestilential  Fevers.    Tide  Moore  (James):    "The 
History  of  Small-pox"   (London,  1815),  p.  8. 

2  De  Mailla  (Jos.  A.  M.):   "Histoire  Generale  de  la  Chine"   (Paris,  1785),  tome  i. 
<Moore.) 

(1) 


2  THE   ACUTE    EXANTHEMATA. 

1122  B.C.).  The  name  given  to  the  malady  in  this  treatise  is  Tai-tou, 
which  means  venom  from  the  mothers  breast. 

The  clinical  description  of  the  disease  is  fairly  clear,  the  symp- 
toms consisting  of  fever  and  an  eruption  of  pustules,  which  increase  in 
size  and  go  through  the  various  stages  of  suppuration,  flattening,  and 
crusting.  In  the  same  work  inoculation  is  mentioned  as  having  been 
practiced  during  the  seven  previous  centuries,  although  Chinese  tradi- 
tion has  it  that  it  was  invented  in  the  dynasty  of  Song,  about  590  years 
before  Christ.3 

Moore,4  referring  to  Father  d'Entrecolles,  also  a  Jesuit  missionary, 
as  being  versed  in  the  literature  of  this  subject,  states  that  small-pox 
was  known  in  China  from  the  earliest  ages.  Among  other  facts  he 
describes  a  method  of  communicating  the  disease,  known  as  "sowing 
the  small-pox,"  which  was  occasionally  practiced,  though  generally 
disapproved  of.  It  was  generally  performed  by  planting  some  of  the 
crusts  in  the  nostril.  This  is  the  first  account  of  the  inoculation  of 
the  disease.  It  is  further  stated  that  the  Chinese  worshiped  a  goddess 
who  presided  over  small-pox.  This  is  a  strong  confirmation  of  the 
antiquity  of  the  malady  in  China,  which  some  erudite  Chinese  scholars 
believe  to  have  prevailed  at  least  3000  years  before  the  Christian  era. 
Orth,5  in  a  recent  critical  review  of  this  subject,  concludes,  as  a  result 
of  other  writings  and  from  traditions  of  the  early  missionaries,  that  we 
are  justified  in  believing  small-pox  in  China  to  have  been  originally 
of  a  benign  type,  becoming  malignant  later  on,  though  this  is  not  made 
plain  in  the  "Treatise  from  the  Heart/'  etc. 

India. — In  Hindoostan,  according  to  the  traditions  of  the  Brah- 
mans,  small-pox  is  of  remote  antiquity.  This  is  confirmed  by  their 
sacred  books,  as  well  as  by  the  mythology  of  the  Hindoos.  Several 
names  are  given  to  it  in  the  ancient  Sanskrit  language.  Sonnerat,6  a 
man  of  letters  sent  to  India  by  Louis  XV  of  France  to  collect  in- 
formation concerning  the  ancient  writings  of  the  country,  reports  that 
several  goddesses  worshiped  in  India  were  supposed  to  preside  over 
small-pox,  and  to  determine  the  fate  of  those  afflicted  with  the  disease. 


!  "M6moires  concernant  1'Histoire,  les  Sciences,  etc.,  des  Chinoises,  par  les  Mis- 
sionnaires  de  Pekin,"  tome  iv,  p.  392;  also,  "Lettres  Edifiantes  et  Curieuses  par  des 
Missionnaires  de  la  Compagnie  de  Jesus"  (Paris,  1781);  tome  xviii,  p.  351;  et  tome  xxi, 
p.  11. 

*  Moore,  in  this  chapter,  refers  to  James  Moore  (op.  cit.). 

6  Orth  (J.):  "Bemerkungen  ueber  das  Alter  der  Pocken-Kentniss  in  Indien  u. 
China."  Janus,  1900,  No.  viii,  pp.  391-396;  ix,  pp.  452-458. 

8  Sonnerat  (M.):  "Voyages  aux  Indes  Orientales  et  a  la  Chine,  par  ordre  du  Roi, 
depuis  1774  Jusqu'a  1781"  (Paris,  1781),  tome  i,  p.  244. 


E      -5 


o      ~  '5  -3 


o      —    r;    _ 


EARLY    HISTORY.  3 

According  to  Holwell,7  an  English  surgeon  who  resided  many  years  in 
Bengal,  many  forms  of  worship  of  Patragali,  the  small-pox  goddess, 
existed,  and  sacrifices  were  offered  to  propitiate  the  wrath  of  the  fe- 
male divinity.  An  account  of  this  may  be  found  in  the  "Atharva- 
Veda,"  one  of  their  most  sacred  and  ancient  books,  which,  according 
to  the  Brahman  calculation,  was  written  between  two  and  three  thou- 
sand years  ago.  The  same  writer  also  mentions  inoculation  as  being 
practiced  in  India.  It  was  performed  with  all  the  religious  rites  ap- 
pointed in  the  "Atharva-Veda,"  and  delegated  to  a  particular  tribe 
of  Brahmans,  who  were  annually,  at  the  approach  of  spring,  sent  out 
from  the  College  of  Bindooband  to  inoculate  the  people.  Orth  (loc. 
cit.)  has  shown  that  Holwell  and  Moore  were  in  error  in  assigning  a 
description  of  the  worship  of  a  definite  goddess  of  small-pox,  or  even 
the  name  of  such  a  goddess  to  the  "Atharva-Veda";  and  as  a  result 
of  the  researches  of  Joly,8  to  whose  work  he  has  had  access,  states  that 
the  word  Masurika  (the  Sanskrit  equivalent  for  pocken)  does  not  occur 
in  the  above  work. 

According  to  Joly,9  the  history  of  small-pox  in  India  can  be  graph- 
ically divided  into  four  periods,  as  follows: — 

In  the  first  epoch  small-pox  is  still  unknown  as  a  distinct  disease, 
although  it  is  possible  that  it  existed  as  one  of  the  countless  diseases 
of  the  skin,  of  the  ancient  Indian  medicine. 

During  the  second  epoch  it  is  described  under  the  name  of  Ma- 
surika, "Linsendisease,"  as  one  of  the  lesser  ills,  and  in  the  third  epoch 
it  is  distinguished  from  the  minor  ailments,  and  described  as  a  distinct 
disease,  with  even  suggestions  as  to  the  remedies  employed  against  it. 

In  the  fourth  epoch  certain  other  conditions  were  first  recognized 
as  variations  of  small-pox. 

Greece. — When  we  consider  the  pathology  of  the  ancient  Greeks 
and  their  conception  of  febrile  disease  in  particular,  we  cannot  wonder 
at  their  ambiguity  in  treating  of  the  pestilential  or  malignant  fevers. 
Local  symptoms  and  eruptions  on  the  skin  were  subordinate,  and  con- 
sidered of  little  moment  excepting  as  they  denoted  the  progress  made 
on  the  part  of  nature  in  expelling  the  peccant  humors  of  the  disease. 
Thus,  we  are  not  always  certain  of  the  exact  meaning  of  such  terms 
as  "ai'flpaxeg,  exO^aara,  £%a<;v6r;u.aTa,  epucriTtF/tag,"  and  cer- 


7  Holwell  (J.  Z.):  "An  Account  of  the  Manner  of  Inoculating  for  the  Small-pox  in 
the  East  Indies,"  etc.   (London,  1767). 

8  Joly  (I.):  Professor  of  Sanskrit  at  the  University  in  Wurzburg. 
8  Joly  (I.):  See  Orth  (loc.  cit.). 


4  THE    ACUTE    EXANTHEMATA. 

tain  other  expressions.  Especially  is  it  to  be  remarked  that  they  did 
not  consider  the  special  forms  of  an  eruption  of  sufficient  importance  to 
serve  as  a  basis  of  classification.  Further,  when  we  consider  that  the 
great  mass  of  Greek  medical  literature  was  destroyed  at  a  very  early  date, 
we  cannot  expect  to  obtain  from  their  writings  any  definite  information 
concerning  the  diseases  under  consideration.  Hippocrates  (460-377 
B.C.)  in  his  voluminous  writings  does  not  give  us  any  definite  informa- 
tion concerning  the  exanthemata.  In  the  third  book  of  "Epidemics" 
mention  is  made  of  certain  eruptive  diseases  occurring  during  "a  pesti- 
lential constitution  (xardcJTaai^  /to<//o&7$)/'  which  he  speaks  of  as 
"anthrakes,"  and  other  affections  called  seps  (af^)  or  septic;  great 
pustular  eruptions  (exOvfiara};  "and  in  many  cases  great  vesicular 
eruptions  (  eoTi^Teg  )-"10  In  the  second  book  of  "Epidemics,"  which 
is  supposed  to  have  been  written  by  one  of  his  pupils,  the  following 
occurs:  "Anthrakes  appeared  at  Cranon  in  a  very  hot  and  rainy  sum- 
mer, mostly  with  a  south  wind;  ichors  or  humors  (t^wpeg)  collected 
under  the  skin,  and  these,  being  confined,  became  hot  and  excited 
itching;  then  there  arose  phlyctamides,  or  blisters  (<jb>li>*Tcuvt5e$), 
as  if  caused  by  fire,  and  the  patients  experienced  a  burning  under  the 
skin."11  These  passages,  which  possibly  refer  to  small-pox,  have  given 
rise  to  much  discussion  as  to  the  real  meaning  Hippocrates  intended 
to  convey.  Krause12  claims  that  the  term  "anthrakes"  refers  to  small- 
pox, while  Littre13  is  of  the  opinion  that  the  use  of  the  plural  form  of 
Ihis  word  means  that  many  people  were  afflicted  with  a  single  lesion, 
rather  than  that  many  lesions  occurred  on  the  same  body:  a  distinc- 
tion we  will  not  attempt  to  follow.  At  any  rate,  the  description  given 
by  Hippocrates  in  this  connection  is  not  sufficiently  definite  to  enable 
us  to  affirm  that  small-pox  was  known  to  the  ancient  Greeks.  The 
term  applies  to  various  diseases,  and  may  have  included  small-pox,  as 
some  believe. 

Rome. — Among  the  ancient  Romans  probably  the  first  description 
which  applies  to  small-pox  was  given  by  Philo,  a  Jewish  author,  who 
lived  during  the  time  of  the  Roman  Empire  (40  A.D.).  In  his  "Life 
of  Moses"14  he  gives  a  commentary  on  the  Egyptian  plague,  to  which 


10  Greenhill    (W.    A.):    "Notes  on   the  Translation   of   Rhazes   on    Small-pox  and 
Measles"   (London,  1848),  p.  146. 

11  Ibid. 

12  Krause  (C.  F.  Th.):  "Ueber  das  Alter  der  Menschenpocken  und  anderer  exan- 
thematischer  Krankheiten"   (Hanover,  1825). 

18  LittrS  (M.  P.  E.):  "CEuvres  d'Hippocrate  completes,"  etc.  (Paris,  1839-61). 

14  Philo  (Jud.):  "Vita  Mosis,"  I,  C.  22.    Ed.  Tauchnitz  (Bonn,  1838),  tome  iii,  p.  151. 


EARLY    HISTORY.  5 

reference  has  previously  been  made,  in  which  he  says:  "There  ap- 
peared suddenly  exanthemata,  those  afflicted  having  phlyktdnes  filled 
with  pus,  which  we  may  suppose  to  have  been  caused  by  hidden  fire. 
From  the  great  suffering  natural  to  the  formation  of  festers  (  e/baj(7<g) 
so  extensive,  their  bodies  were  tortured  and  their  minds  were  filled 
with  horror.  The  lesions  thus  thrown  out  soon  merged  into  extensive 
blisters  filled  with  pus,  as  if  the  parts  had  been  burned.  It  extended 
over  the  whole  body  from  the  head  to  the  feet."  In  commenting  on 
this  Haeser15  says:  "Although  Philo  does  not  say  that  he  had  ever 
observed  such  a  disease,  yet  it  is  not  to  be  supposed  that  the  descrip- 
tion which  fits  so  aptly  to  the  confluent  form  of  small-pox  could  be  a 
product  of  Philo's  imagination." 

In  the  reign  of  Trajan  (98-117  A.D.)  the  works  of  Herodotus  are 
of  the  greatest  importance.  In  writing  of  the  fevers  which  prevailed 
at  the  time,  "especially  the  dyscrasic  rather  than  the  simple  form," 
he  says:  "There  appeared  over  the  entire  body  spots  similar  to  flea- 
bites;  while  in  the  malignant  and  pestilential  fevers  these  eruptions 
assumed  a  blister-like  character,  some  becoming  like  the  antlirakes."™ 
Fearing  lest  too  much  importance  would  be  attached  to  this,  he  adds: 
"All,  however,  are  symptoms  of  a  bad  blood  and  of  a  chymus  which 
eats  through  the  tissue.  The  eruptions  on  the  face  are  the  most  malig- 
nant. It  is  worse  to  have  many  than  few;  the  size,  moreover,  is  of 
importance,  for  the  large  are  more  malignant  than  the  small.  Like- 
wise those  which  soon  disappear  are  more  malignant  than  those  which 
remain  a  longer  time  on  the  surface,  and  those  which  smart  are  worse 
than  those  which  only  itch.  Those,  however,  which  break  out  while 
the  bowels  are  constipated  or  when  only  moderate  diarrhoea  exists  are 
favorable,  but  those  eruptions  are  bad  which  appear  with  much  .diar- 
rhoea and  vomiting.  When,  however,  with  the  appearance  of  the  erup- 
tion the  diarrhoea  ceases,  it  is  favorable."  Various  sequelae  followed 
the  exanthemata,  such  as  malignant  fevers,  although,  for  the  most 
part,  there  remained  only  an  enfeebled  condition.  Herodotus  says 
further  that  the  anthrax  wanders  from  one  people  to  another,  and  in 
most  instances  is  due  to  certain  epidemic  influences. 

Not  only  was  it  observed  that  the  disease  was  prone  to  appear  on 
the  face,  but  that  its  severity  depended  upon  the  number  of  pustules 
present.  Again,  as  in  confluent  small-pox,  the  blending  of  pustules 


1B  Haeser   (H.):    "Geschichte  der  Epidemischen   Krankheiten"    (Jena,   1865),   p.   27. 
18  Various  terms  are  used  by  writers  in  describing  the  same  disease;  thus,  herpetic, 
phlegmonous,  erysipelatous,  and  leprous  seem  to  be  used  synonymously. 


6  THE    ACUTE    EXANTHEMATA. 

forming  large  blister-areas  is  clearly  shown  in  the  description  here 
given. 

Rome  in  166  A.D.  was  insanitary  in  the  extreme.  War,  famine, 
and  pestilence  followed  in  quick  succession.  The  returning  troops  of 
Lucius  Verus  and  Avidius  Cassius  had  scarcely  passed  in  triumph  into 
the  Imperial  City  when  the  plague  broke  out  in  a  most  fatal  form. 
During  a  period  of  fifteen  years  there  followed  a  series  of  distempers 
variously  described  and  variously  named.  The  main  features,  accord- 
ing to  Galen,  were  as  follow:  "Xotable  was  the  extensive  territory  over 
which  the  disease  spread,  from  the  boundaries  of  the  Persian  Empire 
to  the  Gallic  frontier,  and  from  the  Mediterranean  to  the  Rhine.  This 
was  attributed  to  the  returning  armies  and  their  followers  from  Syria 
and  intervening  countries.  The  fatality  of  the  disease  was  so  great, 
especially  among  the  poor,  that  corpses  were  carted  out  of  the  city  in 
wagon-loads,  and  a  general  fear  prevailed  among  the  people.  At  the 
outset  the  principal  symptoms  were  foul  breath  and  redness  of  the 
mouth.  The  skin  was  not  hot,  but  the  patient  seemed  tormented  by 
an  internal  heat.  Oftentimes  the  oncoming  of  the  distemper  might  be 
recognized  by  these  symptoms  alone.  Diarrhoea  was  an  alarming  symp- 
tom, which  usually  appeared  from  the  seventh  to  the  tenth  day,  and 
many  died  at  this  time.  The  most  conspicuous  feature,  however,  as 
well  as  the  most  constant,  was  an  eruption  of  the  skin.  It  appeared 
on  the  ninth  day,  which  was  considered  a  critical  period  of  the  disease. 

"The  eruption  in  most  instances  was  pustular,  but  always  dry. 
The  lesions  were  closely  crowded  together,  covered  the  whole  body,  and 
at  the  height  of  the  disease  presented  a  blackish  appearance  (e%av- 
^fiara  u&avaroi$  7&£t<7Tot£  {IKV  «?«;£(j§>7,  naai  be  £^pa).  When 
recovery  took  place  the  upper  part  of  the  pustules  was  cast  off  in  the 
form  of  a  crust,  leaving  the  base  of  the  pustule,  and  in  some  instances 
the  normal  skin.  Healing  ( jbioivtouTo)  took  place  soon  after,  usu- 
ally from  one  to  two  days.  When  the  lesions  contained  no  pus,  the 
eruption  presented  a  rough  or  chapped  appearance.  After  the  crusts 
were  cast  off  recovery  progressed  rapidly."17  The  contagious  nature 
of  the  disease  and  the  great  dread  it  inspired  may  be  inferred  from 
the  words  of  Ammianus  Marcellinus.18 


17  See  Haeser  (op.  cit.,  pp.  30  et  seg.). 

18  "Et  quoniam  apud  eos   (Romanes),   ut  in  capite  mundi,  morborum  acerbitates 
Celsius  dominantur,  ad  quos  vel  sedandos  omnis  professio  medendi  torpescit,  excogitatum 
est  adminiculum  sospitale,  ne  quis  amicum  perferentem  similia  videat,   additumque  est 
cantionibus    paucis    remedium    aliud    satis    validum,    ut    famulos    percentatum    missos, 
quemadmodum  valeant  noti  hac  segritudine  conligati,  non  ante  recipiant  domum,  quam 
lavacro  purgaverint  corpus."    Ammianus  Marcellinus  (ed.  Hamburg,  1609),  lib.  xiv,  p.  16. 


EARLY    HISTORY.  7 

It  seems  evident,  therefore,  that  Galen,  in  common  with  Syden- 
ham  of  more  recent  time,  observed  a  series  of  epidemics  occurring  in 
successive  years,  varying  in  malignancy,  and  from  their  descriptions  it 
is  highly  probable  that  they  included  small-pox  with  various  other  dis- 
eases. According  to  Haeser,  there  can  be  no  doubt  that  in  the  ma- 
jority of  cases  in  which  exanthemata  appeared  it  was  small-pox.  Fur- 
ther he  says:  "The  conditions  which  Galen  describes  apparently  relate 
to  SCARLET  FEVER,  measles,  and  probably  small-pox,  as  well  as  dysen- 
tery, which  is  so  frequently  associated  with  exanthematous  diseases. 
It  is  highly  probable  also  that  some  may  refer  to  variola  sine  variolis." 
This  view  has  also  been  held  by  Krause.  Hecker,19  on  the  contrary, 
while  acknowledging  a  close  similarity  to  the  confluent  form  of  small- 
pox yet  rejects  it  in  favor  of  malignant  typhus  fever.  Later  we  have 
in  the  writings  of  Eusebius,  who  lived  during  the  reign  of  Diocletian 
and  Galerius  (302  A.D.),  the  following:  "Although  the  usual  rains  had 
brought  the  necessary  crops,  there  appeared  unexpectedly  a  famine  and 
plague  (Xt^og  £cu  hoftio^),  followed  by  the  appearance  of  another 
disease  (eTepoi>  nvog  voGYiuairog),  which  may  be  described  as  fol- 
lows: It  was  a  sore  or  an  eruption  (e/L^o;,  which  Haeser  renders 
schwaren,  p.  25)  which,  owing  to  its  burning  character,  received  the 
name  anthrax.  It  was  not  only  dangerous  to  life  from  its  wide  .dis- 
tribution over  the  body,  but  its  tendency  to  attack  the  eyes  caused 
many  men,  women,  and  children  to  be  deprived  of  their  sight."  This 
we  recognize  as  one  of  the  main  features  of  confluent  small-pox,  and 
further  confirms  the  opinion  that  the  description  applies  most  accu- 
rately to  this  disease. 

Commenting  on  these  writers,  Haeser  says:  "From  which  it 
appears,  without  doubt,  that  a  knowledge  of  small-pox  among  the 
ancient  Greeks  and  Eomans  probably  existed,  although  one  cannot, 
with  absolute  certainty,  either  affirm  or  deny  this  assertion." 

In  570  A.D.  Marius  of  Avenches,  Bishop  of  Lausanne,  describes  a 
violent  malady  which  broke  out  in  Italy  and  France,  characterized  by 
"relaxation  of  the  bowels  and  variola."20  This  is  the  first  mention  of 
the  word  variola,  and  some  suppose  it  to  refer  to  small-pox  (Willan,21 
Paulet22).  Others,  with  Moore,  who  quotes  extensively  from  Gregory, 


18  Hecker  (J.  F.  C.):  "De  Peste  Antoniniana  commentatio"  (Berlin,  1835). 

20  "Hoc    anno    (570)    morbus    validus    cum    profluvio    ventris,    et    variola    Italiam 
Galliamque  afflxit."     "L'Histoire  des  Gaules,"  etc.,  Bouquet.     (See  Moore,  p.  6.) 

21  Willan  (Robert):  Miscellaneous  works,  edited  by  Ashby  Smith   (London,  1821). 

22  Paulet  (Jean-Jacques):  "L'Histoire  de  la  Petite  V6role,"  etc.  (Paris,  1768),  tome 
i,  Art.  3. 


8  THE   ACUTE    EXANTHEMATA. 

believe  that  it  more  accurately  describes  the  bubonic  plague.  It  re- 
mained several  years,  and  in  580  ravaged  nearly  the  whole  of  the 
Gallic  provinces.  It  was  observed  by  Gregory,  Bishop  of  Tours,23  who 
described  the  disease,  as  follows:  "It  was  characterized  at  the  beginning 
by  high  fever  and  vomiting,  severe  pain  in  the  back  (renumque  nimius 
dolor),  and  a  feeling  of  weight  in  the  head  and  neck.  The  vomited 
matters  were  either  yellow  or  green  in  color.  Several  names  were  given 
to  it  by  physicians  and  ecclesiastics,  such  as  lues  cum  vesicis,  also  pusula, 
pustulce,  and  morbus  dysentericus  cum  pusulis.  The  country-folk  called 
the  disease  corales, — i.e.,  pustulas, — because  they  believed  that  by  ap- 
pearing on  the  surface  it  purified  the  system.  It  began  in  August  and 
afflicted  especially  infants  and  young  people,  although  adults  were  by 
no  means  spared.  The  most  conspicuous  feature,  however,  was  a  pain- 
ful exanthem,  which  broke  out  over  the  entire  body,  especially  con- 
spicuous on  the  face,  hands,  and  feet.  It  consisted  of  innumerable 
small  pustules,  which  were  of  a  whitish  color  and  hard  to  the  touch. 
Much  swelling  was  likewise  observed,  especially  about  the  eyes;  so  that 
temporary  blindness  frequently  ensued.  The  physicians  not  only  failed 
to  allay  the  distemper,  but  what  they  did  seemed  to  aggravate  the  dis- 
ease; hence  St.  Martin  was  appealed  to,  and  water  from  his  tomb  was 
sprinkled  over  the  afflicted.  Many  died  during  the  thickening  of  the 
poison  (veneno  incrassante)."  This  latter  applies  to  the  stage  of  sup- 
puration and  crust-formation  of  small-pox. 

Austrigild,  wife  of  Guntram,  King  of  Burgundy,  succumbed  to 
the  pestilence,  and  on  her  death-bed  bound  her  husband  by  an  oath  to 
sacrifice  upon  her  tomb  Nicholas  and  Donatus,  the  two  physicians  who 
had  attended  her  in  her  illness.  Whether  the  pestilence  was  one  of 
small-pox  or  bubonic  plague  (morbus  inguinarius),  there  exists  some 
difference  of  opinion,  for  the  ecclesiastic  mind,  although  it  has  given 
us  many  valuable  data,  does  not  always  tend  to  accuracy  in  recording 
medical  phenomena.  Hecker,  however,  is  of  the  opinion  that  the  pust- 
ular pest  of  the  sixth  century  undoubtedly  refers  to  small-pox.24 

Arabia.  —  The  year  569  A.D.,  according  to  Gibbon,  was  an  au- 
spicious one  for  the  Mussulman,  for  it  produced  Mahomet,25  the  siege 
of  Mecca  or  Elephant  War,  and  the  first  appearance  of  small-pox  and 

28  Gregory:  "Historia  Francorum,"  ed.  Migne  (Paris,  1849),  lib.  v,  cap.  35. 

24  Hecker  (J.  F.  C.):  "Die  Grossen  Volkskrankheiten  des  Mittelalters"  (Berlin, 
1865),  p.  14. 

28  "Is  idem  annus  nascentem  vidit  Mohammeden.  Ex  quo  efflcitur  eum  annum 
fuisse  annum  post  Christum  natum  572."  Reiske  (J.  J.):  "Extractum  ex  dissertatione 
inaugural!  exhibente  miscellaneas  aliquot  observationes  Medicas  ex  Arabum  monu- 
mentis"  (1746).  pp.  9  et  seq.,  in  Leiden  Library,  No.  53. 


EARLY    HISTORY.  9 

MEASLES  in  Arabia.  "In  this  year,  at  length,  the  small-pox,  the  mea- 
sles, the  disease  named  nawasal  (scarlatina  s.  RUBEOLA,  Reiske)  and 
kynanthropia,  or  al  kalab,  first  appeared  in  the  land  of  Arabia.  Some 
of  those  distempers  had  occurred  before  to  the  Israelites,  but  never 
had  attacked  Arabia  until  then.  In  this  year  also  there  first  appeared 
certain  trees,  as  the  sylvan  rue  and  the  colocynth.  .  .  .  The 
Ethiopians,  therefore,  at  this  time  carried  the  small-pox  into  Arabia 
who  in  the  days  of  Hippocrates  carried  the  plague  into  Europe."116 

According  to  Moore  (op.  cit.,  p.  53),  Bruce,  of  Kinnaird,  when  at 
Massuah  on  the  Red  Sea,  had  an  opportunity  of  examining  the  "Annals 
of  Abyssinia"  and  other  historic  works  of  the  country,  from  which  he 
quotes  a  manuscript  concerning  the  siege  of  Mecca  by  El  Hameesy. 
This  author  is  in  accord,  for  the  most  part,  with  the  Arabian  writers 
on  the  War  of  the  Elephant,  and  particularly  the  destruction  of  the 
Arabian  army,  which  he  regarded  as  a  miracle  instigated  by  the  devil. 
He  concludes  with  the  statement  that  at  this  time  the  small-pox  and 
the  measles  broke  out  in  Abrahah.27 

Ahron  of  Alexandria,  we  are  informed  by  Rhazes,  wrote  a  treatise 
on  small-pox  and  measles  during  the  life  of  Mahomet,  at  about  the 
time  when  the  latter  was  assuming  the  role  of  prophet.  Erom  the  ex- 
tensive quotations  taken  from  this  author  on  small-pox  and  measles  we 
infer  that  Ahron  was  not  only  held  in  high  esteem  in  Arabia,  but  that 
he  was  familiar  with  small-pox  and  measles  three  centuries  before 
Rhazes  wrote.  Ahron,  it  appears,  was  the  first  to  write  a  treatise  on 
these  diseases. 

During  the  next  thirty  years  the  Arabians  invaded  Syria,  Egypt, 
and  Persia.  That  the  small-pox  accompanied  the  Koran  into  Europe 
we  are  certain,  for  "three  of  the  early  caliphs  were  pitted  with  small- 
pox, and  two  had  white  spots  on  each  of  their  eyes,  probably  from  the 
same  cause,  and  one  fell  a  victim  to  the  disease."28 

Mesue  the  elder  (Masawaih,  857  A.D.),  whose  work  on  small-pox 
is  quoted  by  both  Rhazes  and  Haly  Abbas,  was  chief  physician  to  the 
Caliph  Haroun-al-Raschid. 

At  the  beginning  of  the  eighth  century  the  whole  of  the  eastern 

28  "Quid  sint  Nawasel,  non  invenio  notatum  in  Lexico  Gotico.  Sed  ex  vi  verb! 
Nasali  conclude  exanthematum  genus  esse,  forte  apthas,  forte  etiam,  et  id  potius  febrem 
scarlatinam  purpuram  aut  rubeolos  (Germani  .  .  .  appellant)."  Ibid. 

27  "Hast  thou  not  seen  how  thy  Lord  dealt  with  the  riders  of  the  Elephants?    Did 
he  not  make  their  treacherous  design  an  occasion  of  drawing  them  into  error;  and  send 
against  them  flocks  of  birds,  which  cast  down  upon  them  stones  of  baked  clay,  and  de- 
stroyed them  like  corn  trodden  down  by  beasts."    The  Koran  (Sale,  trans.). 

28  "Historia  Saracen.  Elmacin."     (See  Moore,  pp.  64-65.) 


10  THE    ACUTE    EXANTHEMATA. 

and  southern  coasts  of  the  Mediterranean  was  subdued  by  the  Saracen 
arms.  In  710  they  invaded  Gibraltar,  and  in  731  planted  their  stand- 
ards in  southern  France.  No  one  can  doubt  that  the  existence  of  small- 
pox and  measles,  if  previously  unknown  in  Spain  and  France,  was  now 
evident.  The  second  writer  on  small-pox,  we  are  informed  by  Rhazes, 
was  Bachtishua,  physician  to  Caliph  Almansor,  who  lived  toward  the 
end  of  the  eighth  century.  Measles,  he  thought,  proceeded  from  blood 
mixed  with  a  large  proportion  of  bile,  and  that  very  gross  and  moist 
blood  gave  rise  to  small-pox.  Isaac,  the  Israelite,  flourished  before  the 
beginning  of  the  ninth  century,  and  some  have  even  placed  the  date  of 
his  birth  at  683  A.D.  Little  is  known  of  him,  however,  except  that  he 
was  an  Arabian  writer  who  is  quoted  extensively  by  Ehazes,  and  that 
he  was  familiar  with  small-pox.  From  his  writings  it  is  evident  that 
he  was  likewise  familiar  with  Galen's  pathology,  for  he  divided  small- 
pox into  four  varieties,  according  as  it  proceeded  from  blood,  phlegm, 
black  or  yellow  bile.29 

The  first  complete  description  of  small-pox,  however,  was  given  by 
Abu  Beer  Mohammed  Ibn  Zacariya  al-Razi,  called  Rhazes,  about  910 
A.D.30  It  is  justly  accredited  with  being  the  most  complete  treatise 
of  the  time,  and  still  continues  to  be  regarded  as  a  classic  production. 
We  have  seen  that  the  disease  undoubtedly  existed  in  Europe  many 
centuries  before  the  time  of  Rhazes.  Hence  it  is  not  surprising  that 
he  refers  to  it,  not  as  a  new  disease,  but  as  one  prevailing  in  the  coun- 
try. He  quotes  from  the  writings  of  Hippocrates,  Galen,  Ahron,  and 
others,  which  implies  that  the  disease  existed  among  the  ancient  Greeks 
and  Romans.31  He  called  it  "Dschedrij,"  or  "Jadari"  (Zotutxi) 
while  measles  was  referred  to  as  "Hasbah"  [x^S±] 
:  "You  should  know  that  the  measles  which  are  of  a  deep- 
red  and  violet  color  are  of  a  bad  and  fatal  kind,  and  that  the  small- 
pox in  which  the  pustules  are  yellow,  hard,  close  together,  confluent, 
numerous,  and  of  deep-red  or  violet  color,  and  that  kind  which  spreads 
like  herpes,  and  gives  the  surface  of  the  body  the  appearance  of  vibices, 
are  all  bad  and  mortal."  Accordingly,  measles  was  regarded  as  more 


29  "Sed  variolas  quatuor  modis  sunt:  aut  de  puro  sanguine,  aut  plegmatico,  aut 
cholerico,  aut  melancholico."  Latin  reduct.  Andr.  Turrin,  Piscien  (Lugd,  1516).  (Vide 
Moore,  p.  121.) 

80  Rbazes:  "A  Treatise  on  the  Small-pox  and  Measles,"  by  Abu  Beer  Mohammed 
Ibu  Zacariya  Al-Razl  (commonly  called  Rhazes),,  Translated  by  Greenhill  (London,  1848); 
Sydenham  Society  transactions. 

S1  According  to  Channing,  it  is  highly  probable  that  an  error  was  made  in  the 
Arabic  translation  which  Rhazes  followed;  hence  his  quotations  from  Hippocrates  and 
Galen  are  of  doubtful  value.  (Vide  note  D,  p.  141  Greenhill's  translation.) 


EAKLY    HISTORY.  11 

dangerous  than  small-pox,  excepting  that  the  latter  had  a  great  tend- 
ency to  cause  blindness.  The  pathology  of  Galen  still  obtained,  but 
Khazes  illustrated  more  forcibly  various  morbific  processes  which  take 
place  in  small-pox  and  measles  by  likening  them  to  the  changes  ob- 
served in  wine.  Thus,  "the  blood  of  infants,  like  the  sweet  juice  of 
new-pressed  grapes,  soon  begins  to  work  and  fret;  in  youth  it  is  in  a 
state  of  ebullition  and  full  of  spirit;  in  manhood  it  becomes  strong 
and  settled,  and  in  old  age  weak  and  acid."  In  this  way  he  accounted 
for  the  prevalence  of  small-pox  and  measles  in  early  life,  as  well  as  the 
immunity  conferred  by  one  attack.  Although  he  describes  small-pox, 
measles,  and  possibly  CHICKEX-POX,  yet  he  does  not  draw  a  clear  dis- 
tinction between  them.  He  ascribes  small-pox  to  ebullition  of  the 
blood,  while  measles  was  supposed  to  arise  from  vitiated  bile.  He  also 
speaks  of  a  very  mild  form,  false  small-pox,  which  confers  no  protection 
against  subsequent  infection;  occurring  during  childhood,  and  which  is 
rendered  chicken-pox  in  GreenhilPs  translation  (pp.  30-37).  This  ap- 
pears to  be  the  first  mention  made  of  this  disease.  His  treatment  was, 
for  the  most  part,  highly  rational.  Ehazes  considered  it  desirable  to 
limit  the  number  of  pustules,  for,  in  a  chapter  devoted  to  "The  preser- 
vation from  the  small-pox  before  the  appearance  of  the  disease,  and  the 
way  to  hinder  the  multiplying  of  pustules  after  their  appearance,"  he 
says:  "It  is  necessary  that  blood  should  be  taken  from  children,  youths, 
and  young  men  who  have  never  had  the  small-pox  (especially  if  the  state 
of  the  air,  and  the  season,  and  the  temperament  of  the  individuals  be 
such  as  we  have  mentioned  above)  before  they  are  seized  with  the  fever, 
and  the  symptoms  of  the  small-pox  appear  in  them.  A  vein  may  be 
opened  in  those  who  have  reached  the  age  of  fourteen  years,  and  cup- 
ping-glasses must  be  applied  to  those  who  are  younger,  and  their  bed- 
rooms should  be  kept  cool. 

"Let  their  food  be  such  as  extinguishes  heat.  Soup  of  yellow 
lentils;  broth,  seasoned  with  the  juice  of  unripe  grapes;  kid's-foot 
jelly;  broth  made  of  woodcocks,  hens,  and  pheasants,  may  be  partaken 
of.  Their  drink  should  be  water  cooled  with  snow,  or  pure  spring- 
water,  cold,  with  which  their  dwellings  may  also  be  sprinkled.  Let 
them  frequently  eat  acid  pomegranates,  and  suck  the  inspissated  juices 
of  acid  and  styptic  fruits,  as  pomegranates,  citrons,  etc.  When  the 
temperament  is  hot,  and  there  is  much  inflammation,  the  patient  may 
take,  in  the  morning,  barley-water  carefully  prepared,  to  which  is  added 
a  fourth  part  of  acid  pomegranate- juice;  but,  if  the  heat  be  less,  barley- 
gruel  and  sugar  may  be  given  in  the  morning,  and  vinegar,  lentils,  and 


12  THE   ACUTE    EXANTHEMATA. 

especially  the  juice  of  unripe  grapes  may  be  added  to  the  food;  for,  by 
means  of  these  you  will  be  able  to  thicken  and  cool  the  blood  so  as  to 
prevent  the  eruption  breaking  out.  This  regimen  is  of  great  service 
in  all  times  of  pestilence,  for  it  diminishes  the  malignity  of  pestilential 
ulcers  and  boils,  and  prevents  pleurisies,  quinsies,  and,  in  general,  all 
distempers  arising  from  yellow  bile  and  from  blood.  ...  In  the 
middle  of  the  day  let  the  patient  wash  himself  in  cold  water,  and  go 
into  it,  and  swim  about  in  it.  He  should  abstain  from  new  milk,  wine, 
dates,  honey,  and,  in  general,  from  sweet  things  and  dishes  made  of  a 
mixture  of  flesh,  onions,  oil,  butter,  and  cheese;  from  lamb,  beef, 
locusts,  young  birds,  high-seasoned  things,  and  hot  seeds.  When  the 
season  is  pestilential  and  malignant,  or  the  temperament  is  hot  and 
moist  and  liable  to  putrefaction,  or  hot  and  dry  and  liable  to  inflam- 
mation, together  with  this  regimen  the  patient  must  take  some  of  the 
remedies  which  we  are  about  to  describe.  To  those  who  are  of  a  hot, 
dry,  inflammable  temperament  give  those  garden-herbs  which  are  cool- 
ing, moist,  and  extinguish  heat,  such  as  purslain,  Jew's  mallow,  straw- 
berry-blite,  and  also  gourds,  serpent-cucumbers,  cucumbers,  and  water 
melons. 

"As  to  melons,  especially  sweet  ones,  they  are  entirely  forbidden, 
and  if  the  patient  happen  to  take  any  he  should  drink  immediately 
after  it  the  inspissated  juices  of  some  of  the  acid  fruits.  He  may  be 
allowed  soft  fish  and  buttermilk.  .  .  .  With  respect  to  those  who 
are  fat,  fleshy,  and  of  a  white-and-red  complexion,  you  may  be  content 
to  let  them  eat  such  foods  as  we  first  mentioned,  consisting  of  any  cool- 
ing and  drying  things.  They  should  be  restricted  from  labor,  bathing, 
venery,  walking,  riding,  exposure  to  the  sun  and  dust,  drinking  of  stag- 
nant waters,  and  eating  fruits  or  herbs  that  are  blasted  or  moldy.  Let 
their  bowels  be  kept  open.  .  .  .  Let  them  abstain  from  figs  and 
grapes;  from  the  former  because  they  generate  pustules  and  drive  the 
superfluous  parts  to  the  surface  of  the  skin,  and  from  the  latter  because 
they  fill  the  blood  with  flatulent  spirits,  and  render  it  liable  to  make  a 
hissing  noise  and  to  undergo  fermentation.  If  the  air  be  very  malig- 
nant, putrid,  and  pestilential,  their  faces  may  be  bathed  with  sanders- 
water  and  camphor,  which  (with  God's  permission)  will  have  a  good 
effect. 

"All  the  pustules  that  are  very  large  should  be  pricked,  and  the 
fluid  that  drops  from  them  should  be  soaked  up  with  a  soft,  clean  rag 
in  which  there  is  nothing  that  may  hurt  or  excoriate  the  patient.  If 
the  patient's  body  be  excoriated,  put  under  him  the  fresh  leaves  of  the 


EARLY    HISTORY.  13 

lily,  and  besprinkle  him  with  an  aromatic  powder,  roses,  and  myrtle; 
and,  if  any  part  be  ulcerated,  then  sprinkle  it  with  the  red  aromatic 
powder  composed  of  aloe,  frankincense,  sarcocol,  and  dragon's  blood." 

As  a  sample  of  remedial  measures  the  following  may  be  quoted: — 
"Take  of  the  best  old  vinegar,  depurated,  three  pints, 

Acid  Pomegranate-juice, 

Acid  juice  of  Citrons, 

Juice  of  unripe  Grapes, 

Juice  of  wart-leaved  Rhubarb, 

Expressed  juice  of  Syrian  white  Mulberries, 

Infusion  of  Sumach, 

and  of  Burberries,  of  each,  one  pint, 

Expressed  juice  of  Lettuce, 

Expressed  juice  of  Tarragon,  of  each,  one-quarter  of  a  pint, 

Decoction  of  Jujubes, 

Infusion  of  Lentils,  of  each,  one  pint  and  a  half; 
Mix  them  all  together,  add  to  them  three  pounds  of  sugar,  and  boil  the 
whole;  then  take  half  a  pound  of  tabasheer,  and  of  common  camphor, 
and  put  them  into  a  clean  mortar  after  they  have  been  well  pounded; 
pour  upon  them  a  little  of  this  syrup,  hot,  and  work  them  quickly  with 
a  pestle  until  they  are  dissolved;  then  mix  them  with  the  whole  and 
continue  stirring  it  from  the  beginning  to  end  with  a  stick  of  open  cane 
or  willow-wood  (but  cane  is  preferable),  after  having  thrown  in  taba- 
sheer and  common  camphor  until  they  are  perfectly  united." 

He  thus  alludes  to  the  sequelaj  of  small-pox:  "When  toward  the 
end  of  small-pox  there  is  a  great  perturbation  of  the  humors,  and  the 
patient  is  seized  with  a  very  violent  pain  in  the  leg  or  hand,  or  any 
other  limb,  or  the  pustules  turn  to  a  green  or  black  color,  and  there- 
upon he  becomes  weaker  than  he  was  before,  and  the  weakness  still 
increases  with  the  increase  of  the  pain,  or  the  limb  is  deeply  colored; 
these  are  signs  of  death." 

Following  Ehazes  came  Avicenna  (980-1037  A.D.),  who  speaks  of 
these  affections:  "Dschedrij"  and  "Hasbah";  also  of  a  third  form  of 
exanthem  "Humak"  £_>'£,  ^'  J,  the  meaning  of  which  still  remains  in 
doubt.  Its  symptoms,  as  described,  lie  between  small-pox  and  measles. 
It  was  characterized  by  miliary  pustules  and  pimples,  and  is  less  dan- 
gerous than  the  two  other  diseases;  some  think  it  applies  to  rubella,32 
others  to  varicella.  On  the  last  hypothesis  it  is  stated  by  some  writers 


32Haeser  (H.),  op.  cit.,  p.  64. 


14  THE   ACUTE    EXANTHEMATA. 

that  one  should  wait  until  the  seventh  day  before  making  a  diagnosis, 
which  renders  it  highly  probable  that  it  refers  to  chicken-pox.33 

Avicenna34  was  the  first  to  describe  small-pox  and  measles  sep- 
arately, and  to  recognize  their  contagious  nature.  He  coincided  with 
his  predecessors  that  measles  was  a  bilious  small-pox,  and  observed  an 
important  symptom,  ''that  in  it  more  tears  flow,"  and  that  difficulty  of 
breathing  was  greater  than  in  small-pox.  He  departed  from  the  treat- 
ment of  Khazes,  cautioned  against  cooling  the  body,  and  advised  sweat- 
ing to  be  encouraged  by  warm  coverings.  He  ordered  that  on  the 
seventh  day  the  pustules  should  be  opened  with  a  golden  needle,  for 
popular  opinion  ascribed  to  gold  greater  healing  properties  than 
pertained  to  other  metals.35 

A  change  in  treatment  may  already  be  noted,  which  reached  its 
height  in  the  sixteenth  century,  when  the  cooling  measures  advocated 
so  strongly  by  Ehazes  were  being  replaced  by  the  hot  or  expelling 
agents  against  which,  later,  Sydenham  so  strenuously  fought.  Aver- 
roes,  a  Spanish  Moor  (died  1198  A.D.),  was  the  first  to  ascribe  thera- 
peutic effects  to  colors.  Thus,  "white  was  refrigerant,  and  red  was  hot, 
from  the  fiery  particles  with  which  it  manifestly  abounded." 

Franciscus36  de  Pedemontium,  who  lived  in  the  vicinity  of  Naples 
about  1330,  wrote  a  supplement  of  Mesue  the  elders  compilation  of 
Galen  and  the  Arabian  writers,  in  which  small-pox  is  treated  of  at 
length.  In  the  treatment  of  the  disease  he  remarked  that  red  bed- 
coverings  and  warm  air  tend  to  expel  pustules  to  the  surface;  further, 
he  recommended  that  the  blood  be  carried  to  the  surface  by  looking 
on  red  substances,  for,  "according  to  Avicenna,  the  sight  of  red  bodies 
moves  the  blood." 

The  Arabian  writers  called  attention  to  the  fact  that  in  small- 
pox the  eruption  appeared  about  the  mouth,  nose,  and  eyes,  and  that 
the  lungs  were  frequently  affected.  They  recognized  diarrhoea  as  a 

88  "Aliquando  apparent  variolae  similes  blactis,  et  aliquis  medicus  dixit,  quod 
blactiae  vertantur  in  variolas.  Et  inveni,  quod  est  differentia  inter  has,  quia  blactiae 
sunt  rubeae  et  apparent  in  superflcie  cutis,  sicut  ignis  persicus,  et  non  sunt  profundae 
eminentiae  nee  eminentes."  Mesue,  Junior.  (Vide  Moore.) 

84  Avicenna,  lib.  iv,  Fen.  i,  cap  10.  (Tide  Haeser,  op.  cit.,  p.  70.) 
5  "In  declinatione  vero,  ex  quo  sunt  maxime  grossse  et  magnae  variolae,  debent 
cum  acu  de  auro  rumpi,  s.  cum  dicto  acu  a  duobus  lateribus,  vel  a  tribus,  vel  a  quatuor, 
secundum  quod  variolae  sunt  magnae  quantitatis  vel  paucae,  perforentur  et  dimittantur, 
quod  sanies  proprie  sine  aliqua  expressione  manaverit  et  exsiccetur  suaviter  cum  cotone 
sine  aliqua  violentia  et  minima  expressione."  Gentilis  de  Fulgineo  (mor.  1348),  cit.,  p. 
Per.  Grtiner,  p.  28.  "Aliquando  scinduntur  cum  forpicibus  capita  corum,  ne  iterum 
claudantur."  Valesc.  de  Taranta.  (Vide  Gruner:  "Fragmenta"  [Jena,  1790],  p.  48.) 

38  "Supplement  Operib.,"  Joan.  Mesue,  Damas. ;  Francis,  de  Pedemont.,  "de  Febre 
Putrid"  (Venet,  1602),  cap.  6.  (Vide  Moore.) 


EARLY    HISTORY.  15 

fatal  sign,  and  a  tremulous  heart  in  the  eruptive  stage  as  a  precursor 
of  death.  To  favor  the  eruption  when  it  was  delayed  beyond  the 
fifth  day,  hot  drinks  were  given,  and  some  wrapped  the  body  in  red 
cloth,  which  was  supposed  to  have  expelling  properties,  and  medicines 
of  a  red  color  were  recommended  by  Avicenna.  Eipe  pustules  on  the 
face  and  hands  were  opened,  after  which  the  parts  were  cleansed  with 
soft  cloths  so  as  to  prevent  deep  scarification.  The  treatment  differed 
but  little  from  that  employed  to-day,  and  even  a  tendency  to  return 
to  red  is  being  advocated  from  recent  observations  as  to  the  chemical 
effect  of  certain  rays  of  light. 

The  writings  of  the  Arabians  were  copied  by  the  Greeks  and 
Latins.  The  first  conspicuous  writer  to  copy  almost  verbatim  the 
Arabian  writings  was  Constantine  the  African  (1075  A.D.),  one  of  the 
best-known  writers  of  the  school  of  Salernum,  who,  in  speaking  of 
small-pox,  says:  "Variolae  arise  from  the  corruption  of  the  putrid 
blood,  and  are  one  of  the  accidents  attending  synochus  (continued 
fever).  The  symptoms  of  this  disease  are  high  fever,  headache,  ulcers 
and  fullness  of  the  eyes  and  face,  malaise,  sore  throat,  cough,  tickling 
in  the  nose,  sneezing,  pricking  upon  the  surface  of  the  body,  because 
the  materies  morbi,  seeking  exit,  pricks  the  flesh  and  skin,  separating 
their  tissues  in  its  efforts  to  escape.  When  you  see  these  symptoms  you 
have  certain  evidence  of  the  coming  of  variola?."37 

Japan. — When  this  country  was  first  visited  by  Europeans  both 
small-pox  and  measles  were  found  to  exist.  Kempfer,38  physician  to 
the  Dutch  embassy  in  Japan,  1690,  informs  us  that  both  small-pox  and 
measles  were  generally  diffused  throughout  the  country  at  that  time. 
In  the  archives  of  the  empire  it  is  stated,  in  the  chronicle  relating  to  the 
principal  events  during  the  reign  of  King  Siomu  (737  A.D.),  that  small- 
pox was  very  mortal  in  all  parts  of  the  empire. 

Great  Britain. — It  is  interesting  at  this  point  to  note  the  progress 
of  the  disease  in  Britain.  In  the  library  of  the  Marquis  of  Buckingham 
there  is  an  ancient  manuscript,  written  partly  in  Latin,  but  principally 
in  the  Irish  language,  denominated  the  "Annals  of  Ulster,"  from  which 
it  appears  that  in  the  year  679  a  grievous  leprosy  prevailed  in  Ireland, 
which  was  called  Bolgach,  and  that  the  same  distemper  reappeared  in 


37  This  is  the  first  time  that  the  term  variola  was  used  in  connection  with  a  dis- 
ease that  we  can  positively  identify  as  small-pox.     In  the  employment  of  the  word  by 
Marius,   previously  noted,   we   are   not  certain  whether   it  related   to   small-pox,   to   the 
bubonic  plague,  or  to  other  eruptions.     (Vide  Constantinus  Africanus,   "De  Morborum 
Cognitione"  [Basel,  1536],  lib.  viii.) 

38  Kempfer  (Engelbert):  "History  of  Japan"  (London,  1727). 


16  THE    ACUTE    EXANTHEMATA. 

742.39  Whether  or  not  this  refers  to  small-pox  we  do  not  know,  ex- 
cepting that  in  Brian's  Irish  dictionary  the  word  "bolgach"  is  trans- 
lated the  small-pox,  and  the  plural,  "bolgaidhe,"  blisters.  This,  it  may 
be  mentioned,  was  thirty  years  before  the  invasion  of  Spain  by  the 
Moors.  It  may  also  be  remarked  that  at  this  time  several  celebrated 
schools  and  academies  flourished  in  Ireland,  which  were  crowded  with 
foreign  scholars.  Many  saints  and  other  missionaries  flocked  here  from 
the  continent  of  Europe  to  receive  instruction,  which  may  explain  the 
early  appearance  in  Ireland  of  what  some  suppose  to  be  small-pox. 
This  seems  confirmed  by  Irish  chronicles  of  the  fourteenth  century, 
when  small-pox  (gala  breac;  i.e.,  the  speckled  disease)  was  generally 
diffused,  in  which  it  is  recorded  that  in  the  year  907  Princess  Elfreda, 
daughter  of  Alfred  the  Great,  "was  sick  of  the  small-pox,  and  recov- 
ered." 

The  next  case  occurred  in  a  grandson  of  the  same  Elfreda,  whose 
death  is  recorded  in  the  Bertinian  Chronicle  as  follows:  "About  Christ- 
mas 961  Baldwin,  the  son  of  Arnolph,  Earl  of  Flanders,  was  attacked 
with  a  disease  which  physicians  called  variola,  or  the  pock,  and  died 
on  the  day  of  our  Lord's  circumcision  following."40  In  the  genealogy 
of  the  Earls  of  Flanders,  preserved  in  the  Cistercian  monastery  and 
published  by  Bouquet,41  it  is  further  recorded  that  Arnolph  the  Great 
begot  Baldwin,  who  died  of  the  variolous  disease,  and  was  buried  in 
St.  Bertin.  According  to  Moore,  this  is  the  first  authentic  mention  of 
the  words  variola  and  pocca  in  the  same  passage.  No  definite  name 
apparently  existed  at  this  time,  either  in  Greek  or  Latin,  for  small- 
pox and  measles.  Pestis,  pestilentia,  and  lues  were  applied  to  these 
in  common  with  other  epidemics.  Pestilentia  ignis,  the  fire-plague, 
was  not  only  applied  to  erysipelas,  but  to  all  dangerous  eruptive  dis- 
orders. It  is  supposed  that  at  this  time  the  word  variola  was  formed. 
It  is  derived  either  from  the  Greek  word  ouo/loc  (varius,  variegatus), 
i.e.,  spotted;  or  from  the  Latin  varus,  as  employed  by  Celsus  and  Pliny 
to  designate  a  pimple;  from  which  the  Spaniards  derived  their  name 
viruelas,  which  the  Italians  liquefied  into  il  vajuolo  and  from  which  the 
French  framed  their  veroh.  The  French  had  also  a  name  in  common 
use  for  small-pox:  piquote  or  picote,  which  may  be  found  in  the  writings 
of  Rabelais  and  other  old  French  authors.  It  appears  that,  when  the 
malady  extended  to  the  north  of  Europe,  the  Saxons,  instead  of  adopt- 

*»  O'Conor    (C.),   Esq.:    "Dissertations  on   the   History  of  Ireland"    (Dublin,    1766). 
40  Bouquet:  "Historiens  des  Francs  et  des  Gauls"   (Paris,  1738),  tome  ix,  p.  79. 
tt  Ibid.,  tome  xiii,  p.  417. 


EARLY    HISTOEY.  17 

ing  the  more  classic  word  variola,  adhered  to  or  invented  the  vernacular 
name  poccadl,  signifying  a  pock,  or  pouch.  The  Anglo-Saxons  adopted 
this  word,  which  was  variously  spelled  by  different  writers, — papulo, 
pockcha,  pocca,  pocc, — until  it  finally  became  pock  and  pox.  The  term 
morbilli,  measles,  from  morbillo, — i.e.,  the  little  disease, — was  first  used 
in  Italy  to  distinguish  it  from  the  great  disease  or  plague,  which  was 
known  as  il  morbo.  When  syphilis  appeared  in  western  Europe  it  was 
also  called  "the  pox"  or  the  "great  pox."  Hence  it  became  necessary 
to  prefix  a  qualifying  term  to  variola,  from  which  we  have  the  English 
small-pox  and  the  French  petite  verole  now  in  use. 

Another  case  of  small-pox  is  recorded  in  the  convent  of  St.  Gall 
at  about  the  same  period.  It  is  stated  that  St.  Gall,  a  venerable  monk, 
having  been  fully  enlightened  in  the  learned  academies  of  Ireland  and 
believing  his  countrymen  no  longer  needed  his  pastoral  care,  resolved 
to  set  out  on  a  pilgrimage  to  convert  the  less-civilized  people  of  Switzer- 
land. Finally  a  convent  was  founded  which  bore  his  name,  in  the 
annals  of  which  the  following  is  recorded:  "Notkarus,  who  died  in  the 
year  of  our  Lord  966,  was  both  monk  and  physician,  being  consulted 
by  Henry  II  of  Bavaria,  who  was  duly  restored  to  health.  He  was  sent 
for  by  the  bishop  of  the  diocese  who  had  been  suddenly  taken  ill. 
Notkarus,  knowing  the  plethoric  regimen  to  which  the  good  prelate 
had  been  accustomed,  bled  him  most  copiously.  After  observing  the 
rich,  inflamed  blood  of  his  patient  he  prognosticated  that  in  three  days 
his  reverence  would  break  out  with  the  small-pox.  The  bishop,  al- 
though fully  prepared,  was  greatly  alarmed,  and  besought  Notkarus  to 
stop  the  dangerous  eruption.  Notkarus  replied  that,  though  it  were 
easily  done,  it  could  not  be  entertained,  as  such  a  procedure  would  in- 
evitably result  in  death.  The  disease  was  therefore  allowed  to  run  its 
course,  and  happily  with  a  favorable  result."42 

In  the  Harleian  collection  in  the  British  Museum  there  is  a  very 
ancient  Anglo-Saxon  manuscript  which  is  supposed  to  have  been 
written  in  the  tenth  century.  It  is  written  in  Saxon  and  Latin,  and 
contains  many  pious  exhortations,  exorcisms,  and  prayers.  One  of 
them  is  as  follows:  "In  the  name  of  the  Father,  of  the  Son,  and  of  the 
Holy  Ghost,  Amen.  N°  May  our  Saviour  help  us.  N°  0  Lord  of 
Heaven!  .  .  .  hear  the  prayers  of  thy  man-servants,  and  of  thy 
maid-servants;  0  Lord  Jesus  Christ,  I  beseech  thousands  of  angels  that 


42  Ekkard   (Junior):    "Liber  de  Casibus   Monast.   Sti.   Galli,"   etc.    (Francofurtum, 
1661),  p.  52. 


18  THE   ACUTE    EXANTHEMATA. 

they  may  save  and  defend  me  from  the  fire  and  power  of  the  small- 
pox; N°  and  protect  me  from  the  danger  of  death;  0  Christ  Jesus! 
incline  your  ears  to  us/'  etc.43  This  affecting  prayer  shows  strongly 
the  terror  which  the  small-pox  inspired  at  that  time. 

There  is  a  similar  monastic  manuscript  in  the  Cottonean  Library 
containing  extracts  from  the  writings  of  Cassiodorus  and  other  primi- 
tive fathers  of  the  church.  In  this  collection  there  is  a  prayer  to  St. 
Nicaise  intended  for  the  consecration  of  charms  made  by  nuns  and 
inscribed  with  the  saint's  name,  to  be  worn  as  a  protection  against 
small-pox.  This  copy,  according  to  Moore,  was  probably  written  in  the 
tenth  century,  as  it  is  followed  by  a  calendar  of  the  paschal  terms  be- 
ginning with  the  year  988,  and  continued  by  successive  hands  to  the 
year  1268. 

"In  the  name  of  our  Lord  Jesus  Christ,  may  the  Lord  protect 
these  persons,  and  may  the  work  of  these  virgins  ward  off  the  small- 
pox. Saint  Xicaise  had  the  small-pox,  and  he  asked  the  Lord  (to  pre- 
serve) whoever  carried  his  name  inscribed. 

"0  Saint  Xicaise!  thou  illustrious  bishop  and  martyr,  pray  for 
me,  a  sinner,  and  defend  me,  by  thy  intercession,  from  this  disease. 
Amen."44 

It  is  of  interest  to  note  the  views  entertained  as  to  the  nature  and 
management  of  the  exanthemata  during  the  thirteenth  and  fourteenth 
centuries.  It  may  be  remarked  that  variola,  morbilli,  rubella,  and 
varicella  were  all  regarded  as  modifications  or  varieties  of  the  same 
disease.  Michael  Scott  (1250  A.D.)  gives  substantially  the  same  pa- 
thology and  treatment  as  given  by  Constantinus  Africanus  and  the 
Arabian  school.  Gilbert  (Gilbertus  Anglicus,  1275)  in  his  "Com- 
pendium of  Medicine,"  the  oldest  English  medical  work  extant,  men- 
tions that  in  small-pox  the  patients  should  be  attentively  guarded  from 
cold;  neither  should  they  have  cooling  medicines,  or  a  cooling  diet. 
He  likewise  advises  the  opening  of  the  pustules  with  a  golden  needle, 
and  says  that  "the  vetulce  provinciates" — i.e.,  the  old  women  of  country 
districts — "recommend  that  the  drink  of  the  sick  should  be  some  burnt 
purple  or  red  ingredients,  which,  like  cloth  dyed  in  grain,  have  a  secret 
virtue  in  curing  the  small-pox." 

Bernard  Gordon  (1305  A.D.),  a  Scotch  physician,  professor  in  the 
University  of  Montpellier,  in  his  "Lilium  Medicinae"  says: — 

"Variola?  and  morbilli  are  certain  abscesses  or  small  pustules  ap- 

43  The  mark  N°  denotes  when  the  exorcist  made  the  sign  of  the  cross. 
**  Biblioth.  Cotton.  Caligula  A.  XV.     No.  30,  p.  125.     (Vide  Moore.) 


EARLY    HISTORY.  19 

pearing  upon  almost  the  whole  of  the  body.  They  belong  to  the  class 
of  infectious  diseases  and  originate  from  corruption  of  the  blood  and 
humors;  variola  rather  from  the  blood  and  morbillus  from  the  bile. 
This  disease  is  produced  by  retention  of  the  menstrual  blood  in  the 
pores  of  the  foetal  membrane,  and  as  nature  becomes  stronger  she  ex- 
pels it  from,  and  cleanses  the  body,  either  in  infancy,  childhood,  or 
adolescence,  rarely  in  youth,  and  rarest  of  all  in  old  age.  The  same 
method  of  evacuation,  however,  is  common  to  all. 

"Exceptionally,  too,  the  disease  arises  from  other  causes, — e.g.,  if 
one  is  begotten  during  the  menstrual  epoch;  and  this  mode  of  origin 
is  very  bad,  because  persons  so  generated  rarely  escape  lepraB  or  some 
other  terrible  sickness.  It  is  also  due  to  bad  regimen,  and  especially 
to  the  use  of  easily  and  quickly  decomposing  foods,  like  milk  and  fish 
at  the  same  meal,  and  particularly  to  warm  and  moist  foods  and  in 
those  who  neglect  phlebotomy.  Fourthly,  the  disease  is  generated 
in  corrupt  and  pestilential  seasons.  Fifthly,  it  is  prone  to  follow 
imperfect  crises  in  sanguineous  fevers.  There  are  thus  five  possible 
causes,  four  of  which  are  of  this  species;  since  some  cases  arise  from 
the  blood,  some  from  the  bile,  some  from  black  bile,  and  some  from 
phlegm. 

"There  are  certain  symptoms  which  foretell  the  approach  of 
variolas:  e.g.,  itching  of  the  nose,  sparks  before  the  eyes,  frightful 
dreams,  redness  of  the  face,  breaking  over  the  whole  body,  and  when 
the  pustules  begin  to  appear  they  look  like  grains  of  millet  or  ant- 
heads.  Then  they  begin  to  multiply  and  enlarge,  next  form  sanious 
crusts,  and  finally  dry  up  and  fall  off." 

In  the  treatment  he  recommends  phlebotomy  (in  the  median  vein 
or  from  the  bridge  of  the  nose)  in  robust  and  phlethoric  patients,  the 
avoidance  of  remedies  adapted  to  drive  in  the  eruption,  and  cautions 
against  the  use  of  inunctions  of  oil,  cold  applications,  and  cold  air  and 
water.  On  the  other  hand,  he  recommends  acid  drinks,  such  as  the 
juice  of  sorrel,  pomegranate,  sour  grapes,  lemons,  and  acid  fruits,  with 
coriander,  water-lily  (nenuphar),  camphor,  etc.  Laxatives  are  to  be 
avoided,  since  the  disease  is  prone  to  occasion  diarrhoea.  Then  the 
entire  body  should  be  wrapped  in  red  cloth.  For  protecting  the  eyes 
he  recommends  a  collyrium  of  coriander,  sumach,  rose-water,  and  white 
of  eggs,  instilled  frequently  into  the  eyes.  The  pitting  of  the  skin  is 
to  be  treated  with  an  ointment  of  litharge,  subcarbonate  of  lead,  burnt 
starch,  powdered  millet-seeds,  oil  of  lilies,  and  wax. 

John  of  Gaddesden,  professor  in  Merton  College,  Oxford,  Ordinary 


20  THE    ACUTE    EXANTHEMATA. 

Physician  to  King  Edward  I  of  England,  in  his  "Rosa  Anglica"  (1305) 
devotes  much  space  to  a  description  of  variola.  He  says:  "Variola? 
take  their  name  from  the  fact  that  they  affect  the  skin  variously 
(varie),  infecting  and  occupying  it  in  different  parts  with  abscesses. 
They  are  caused  by  corruption  of  the  blood,  and  in  this  is  their  point 
of  distinction  from  morbilli  and  punctilli.  Morbilli  are  small  abscesses 
in  the  skin  generated  by  bile.  The  diminution  of  apostemative  dis- 
eases, because  by  reason  of  the  sharpness  of  bilious  matter  they  occupy 
less  space,  yet  those  are,  in  fact,  variolas  of  bilious  matter  and  appear- 
ing in  very  minute  pustules.  Punctilli,  however,  are  infectious,  com- 
monly sanguineous,  as  if  produced  by  the  bite  of  a  flea,  but  lasting  for 
some  time.  Punctilli,  too,  are  of  two  kinds:  large  and  small.  Of  the 
latter  I  had  already  spoken.  The  large  infractions  are  broad,  red,  and 
dusky.  The  same  description  will  apply  to  morbilli,  except  that  they 
are  smaller  and  arise  from  bile. 

"Both  variolas  and  morbilli  arise  from  the  retention  of  menstrual 
blood  in  the  foetus,  and  accordingly  Averroes  says  that  no  one  can  escape 
the  variola?.  They  may  also  be  produced  by  the  use  of  food  or  drinks 
prone  to  putrefaction,  such  as  the  blood  and  juices  of  animals;  from 
the  mixture  of  watery  and  warm  articles  of  food, — e.g.,  wine  and  milk, 
fruit  and  ginger,  fish  and  garlic  or  onions, — which  produces  fermenta- 
tion. The  ingestion  of  much  wine  or  new  beer  in  persons  who  neglect 
phlebotomy  may  also  occasion  the  disease.  It  occasionally  happens, 
too,  that  a  man  suffers  the  disease  twice,  because  in  the  first  attack  the 
materies  morbi  was  not  all  expelled.  A  pestilential  quality  of  the  air 
may  also  produce  variola.  Persons  of  a  warm  and  moist  complexion 
are  more  prone  to  the  disease  than  those  of  a  dry  complexion;  infancy, 
childhood,  and  adolescence  more  than  manhood  and  old  age.  It  occurs 
oftener  in  spring  than  in  winter,  and  frequently  in  autumn  when  pre- 
ceded by  a  warm  and  dry  summer. 

"Variola?  do  not  occur  in  the  foetus  in  utero  because,  first,  the  heat 
here  is  moderated  and  thus  does  not  produce  ebullition;  second,  the 
force  of  nature  is  employed  in  another  direction, — the  formation  of  tis- 
sues; third,  because  there  is  a  lack  of  emunctories;  and,  fourth,  be- 
cause that  menstrual  blood  is  preserved  by  the  heat  of  the  womb  from 
both  ebullition  and  corruption. 

"It  is  also  to  be  remarked  that  it  is  not  necessary  for  everyone  to 
have  the  variola?,  though  Isaac  in  his  fifth  book  on  fevers  says  that  it 
is.  This  statement,  however,  should  be  understood  to  mean  that  every 
one  inherits  a  predisposition  to  the  disease  from  the  menstrual  blood 


EARLY    HISTORY.  21 

remaining  in  the  infant  after  birth.  Now,  unless  this  is  expelled  by 
the  urine,  the  faeces,  the  perspiration,  or  by  phlebotomy,  the  man  will 
actually  suffer  the  disease.  Unless,  indeed,  it  so  happens  that  he  was 
conceived  in  a  perfectly  clean  and  healthy  woman,  after  the  menstrual 
flow,  and  begotten  by  a  father  sound  and  of  good  regimen;  that  the 
child  possesses  a  good  complexion,  is  temperate,  not  gluttonous  or 
irregular  in  living,  which  is  rarely  the  case. 

"The  premonitory  symptoms  in  variolas  in  the  sanguineous  form 
are  pain  in  the  head  and  back  due  to  the  distension  of  the  dorsal  vein 
by  the  excess  of  corrupt  blood.  In  variolas  there  are  redness  and  swell- 
ing of  the  face,  disturbances  of  the  eyes,  and  lacrymation;  but  in  mor- 
billi  the  lacrymation  is  more  marked  and  the  pain  in  the  back  less, 
because  in  the  latter  disease  the  symptoms  are  due  to  the  excessive 
virulence  of  a  small  quantity  of  corrupted  blood,  while  in  variolas  there 
is  great  distension  of  the  narrow  dorsal  vein.  .  .  . 

"Diarrhoea,  bloody  urine,  dyspnoea,  syncope,  are  all  of  bad  omen. 
If  the  eyes  are  affected,  blindness  or  opacities  of  the  cornea  are  fre- 
quently left  behind. 

"Variolas  depart  gradually,  morbilli  abruptly." 

The  treatment  recommended  was  venesection  and  mild  purga- 
tion, acidulous  drinks;  protection  of  the  eyes,  respiratory  organs,  nares, 
mouth,  and  intestines;  promotion  of  desiccation  after  maturation  of 
the  pustules,  and  prevention  of  disfigurement. 

"Then  a  scarlet-red  cloth  should  be  taken  and  the  patient  rolled 
up  completely  in  it  or  in  some  other  red  stuff,  as  I  did  in  the  case  of 
the  son  of  his  majesty,  the  King  of  England  (Edward  I),  when  he  suf- 
fered from  this  disease,  and  I  had  everything  about  his  bed  made  red. 
And  this  cure  was  a  good  one,  and  I  cured  him  without  leaving  any 
traces  of  variolas."  This  treatment,  which  has  received  such  wide 
recognition,  seems  to  have  almost  attained  perfection  in  Japan,  where 
it  is  related  by  Kempfer  (op.  cit.)  that,  the  emperor's  children  being 
stricken  with  variola,  it  was  commanded  that  not  only  the  hangings 
and  bed-coverings  be  of  a  red  color,  but  persons  entering  the  royal 
chamber  be  clad  in  scarlet  gowns. 

Thus  the  Arabians,  copied  by  the  Latins,  continued,  although 
modified  by  deteriorating  influences,  to  be  the  standard  authorities  on 
the  exanthemata  until  the  age  of  the  renaissance  in  the  fifteenth  and 
sixteenth  centuries. 

America. — From  manuscripts  at  our  disposal  it  is  evident  that 
both  small-pox  and  measles  were  carried  to  the  Island  of  St.  Domingo 


22  THE    ACUTE    EXANTHEMATA. 

in  the  year  151 7.45  The  effect  of  the  small-pox  among  a  new  people 
may  be  inferred  from  the  fact  that  of  the  Indians  in  Hispaniola  num- 
bering several  millions,  the  majority  were  either  totally  extinguished 
by  labor,  famine,  or  by  the  small-pox  and  measles.  When  Cortes  sailed 
from  Cuba  in  the  year  1518  for  Mexico  it  is  said  that  an  infected  negro 
slave  covered  with  pustules,  landed  with  the  troops  of  Zempoalla,  from 
whom  the  natives  soon  caught  the  infection,  which  spread  through 
Mexico.  It  is  estimated  that  three  millions  and  a  half  of  people  were 
destroyed  from  this  source,  among  the  victims  being  the  Emperor 
Quetlavaca,  brother  and  successor  to  Montezuma.  The  disease  soon 
spread  to  Caracas  and  wrought  such  havoc  among  the  Indians  that 
they  fled  in  terror  to  the  most  distant  parts,  hoping  to  escape  the  hor- 
rible malady  imported  by  the  whites,  but  only  the  more  rapidly  to 
spread  the  infection.  Handerson46  quotes  Toner  to  the  effect  that 
small-pox  prevailed  among  the  Indians  of  New  England  as  early  as 
1618,  and  its  ravages  were  felt  among  the  white  settlers  of  this  section 
in  1622  and  1638. 

At  this  time  the  spirit  of  adventure  was  strong,  and  various  parts 
of  the  world  were  visited  and  explored.  In  1707  an  epidemic  of  small- 
pox broke  out  in  Iceland,  destroying  16,000  persons,  or  over  a  fourth 
of  the  inhabitants  of  the  island.47  Greenland  next  succumbed  to  small- 
pox in  1733,48  and  it  is  stated  that  it  spread  so  rapidly  and  was  so  fatal 
that  fears  were  entertained  lest  it  depopulate  the  country. 

Like  the  other  exanthemata,  we  have  seen  that  SCAKLET  FEVER  is 
of  uncertain  origin  (see  page  7).  There  can  be  no  doubt,  however, 
that  it  existed  under  various  names  long  before  it  became  recognized 
as  a  special  disease.  Possibly  the  fire-plague  previously  mentioned 
refers  to  it,  and,  as  will  appear,  it  was  at  first  confounded  with  ery- 
sipelas. It  is  highly  probable,  also,  that  the  disease  prevailed  in 
Arabia,  and  is  referred  to  in  the  following  from  Haly  Abbas,  trans- 
lated by  Constantinus  Africanus: — 

"In  this  affection  when  it  reaches  maturity  the  lesions  upon  the 
body  neither  discharge  of  their  own  accord  nor  when  punctured.  The 
eruption  is  of  a  reddish  color,  and  consists  of  millet-seed-sized  papules, 
which  appear,  for  the  most  part,  on  the  face,  although  it  extends  over 
the  whole  body.  Further,  there  is  commonly  swelling  and  redness  of 

"Robertson:  "History  of  America,"  vol.  i,  p.  260. 

"Handerson  (H.  E.):   "Baas's  History  of  Medicine"  (New  York,  1889),  p.  241. 
47  McKenzie  (Sir  George  Stewart):   "Travels  in  the  Island  of  Iceland"    (London, 
1810). 

^Crantz:  "History  of  Greenland,"  vol.  i,  p.  336. 


EARLY    HISTORY.  23 

the  face  and  extremities,  itching  of  the  temples  and  ears,  inflammation 
of  the  nose,  difficulty  of  swallowing,  and  a  feeling  of  heaviness  in  the 
head."49 

It  was  not  until  the  middle  of  the  sixteenth  century,  however,  that 
scarlet  fever  was  positively  recognized  and  accurately  described.  In- 
grassias,  of  Palermo  (1510-1580),  observed  an  epidemic  at  Naples  which 
he  differentiated  from  measles  and  to  which  he  gave  the  name  rossalia 
or  rossania.50  He  emphasized  the  fact  that  it  attacked  children  before 
puberty  and  that  it  seldom  recurred  in  the  same  individual;  that  the 
disease  was  limited  to  the  epidermis,  was  of  a  reddish  color,  invaded  the 
whole  surface,  and  was  accompanied  by  a  fever.  It  is  thought  by  some 
that  the  affection  was  also  observed  in  France  by  Coyttar,51  of  Poitiers, 
in  1578. 

Later,  according  to  Noirot,52  Baillou  described  an  epidemic  oc- 
curring in  Paris  in  157-1  which  he  called  rubiolce  and  distinguished 
from  morbilli  (measles).  He  further  observed  that  it  appeared  like 
erysipelas,  while  variola  and  morbilli  more  closely  resembled  miliary 
herpes.  This  description,  however,  is  not  complete,  and  we  are  left  in 
doubt  whether  or  not  scarlet  fever  was  recognized  in  Paris  at  that  early 
date. 

Soon  after  this  an  epidemic  of  like  character,  supposed  to  have 
come  from  Asia,  appeared  in  the  south  of  Europe  and  was  first  ob- 
served in  Spain,  where  it  was  spoken  of  by  Mercado,53  of  Toledo,  phy- 
sician to  King  Philip  II,  as  follows:  "Although  it  is  commonly  called 
erysipelas,  yet  it  differs  from  the  true  erysipelas  of  the  ancients."  In 
another  place  he  says:  "The  patient  was  suddenly  seized  with  fever, 
headache,  and  retching.  An  intense  redness  appeared  on  the  face  and 
in  the  throat.  The  rash  extended  upward  to  the  eyes,  was  symmetrical 
in  distribution,  and  the  skin  was  slightly  swollen.  Soon  after  the  fever 
increased  and  the  eruption  extended  to  the  neck  and  upper  part  of  the 
trunk.  In  our  suffering  patient  the  blush  was  not  that  of  erysipelas." 

*•  Theor.,  lib.  viii,  cap.  14. 

80  "Nonnulli  morbillos  et  rosaliam  eundem  esse  morbum  existimarunt;  nos  ipsi 
nostrismet  oculis  di versos  eorum  affectos  esse  videmus;  morbilli  enim  racematim  venire 
solent.  .  .  .  Etsl  nonnulla  scarlatinas  symptomata  desiderantur,  tamen  accurata  exan- 
thematis  descriptio,  et  cum  morbillis  et  variolis  comparatio,  hunc  morbum  subintelli- 
gendum  esse  verisimile  reddit."  Ingrassias  (Job.  Philipp):  "De  Tumoribus  praeter 
naturam,"  etc.  (Neapoli,  1553),  cap.  i,  p.  194.  And  more  fully  in  "Informatione  del  pesti- 
foro,  et  contagioso  morbo"  (Palermo,  1576). 

51  Coyttarus  (Joan.):  "De  Febre  purpura  epidemiali  et  contagiosa"  (Parisiis,  1578), 
libri  duo. 

52  Noirot  (M.  Li.):  "Hlstolre  de  la  Scarlatine"   (Paris,  1847). 

53  Mercado  (L.):  "De  Essentia,  Causis,  Signis,  et  Curatione  febris  malignae,  in  qu4 
Maculae  rubentes  similes  morsibus  pullcum  per  cutum  erumpunt"  (Basel,  1584). 


24  THE   ACUTE    EXANTHEMATA. 

Other  Spanish  writers  likewise  mention  the  disease  under  the  name 
garrotillo. 

Early  in  the  seventeenth  century  the  disease  appeared  in  various 
parts  of  Europe.  From  1610  to  1620  severe  epidemics  broke  out  in 
Naples,  Borne,  Malta,  and  Sicily.  It  was  regarded  as  a  new  affection, 
and  many  names  were  applied  to  it,  such  as  ulcera  anginosa,  angina, 
purpurum,  ignis  sacer.  Among  other  writers  it  was  studied  by  Nola, 
of  Naples,54  who  observed  the  following  symptoms:  Redness  of  the 
pharynx,  tongue,  and  tonsils,  with  a  feeling  of  constriction  in  these 
parts,  difficulty  of  swallowing  and  respiration,  offensive  breath,  and  a 
bad  taste  in  the  mouth.  This  was  accompanied  by  an  erysipelatous  in- 
flammation of  the  pharynx  and  the  whole  buccal  cavity,  together  with 
redness  of  the  face  and  neck,  and  violent  fever.  On  the  second  day  the 
swelling  of  the  neck  was  often  well  marked,  and  a  livid  tint  to  the 
mucous  surfaces  was  observed.  Sometimes  crusts  formed  in  the  nares, 
and  small  excoriations  in  the  mouth  were  seen.  Death  often  took  place 
on  the  fifth  or  sixth  day,  although  a  fatal  termination  was  not  infre- 
quent on  the  first  day  of  the  disease.  Its  contagious  nature  was  recog- 
nized, and  it  was  remarked  that  it  appeared  without  prodromata.  It 
prevailed  especially  among  children,  although  in  some  instances  adults 
were  likewise  attacked.  It  was  thought  to  be  more  severe  in  girls  than 
in  boys.  In  commenting  on  this,  Bretonneau55  says:  "The  diffuse 
efflorescence  of  scarlatina  is  clearly  indicated  in  many  passages  where, 
according  to  the  usual  expression  of  the  time,  it  is  termed  erysipelas." 

At  this  time  scarlet  fever  appeared  in  Saxony,  and  was  observed 
in  Poland  by  Boring,56  of  Breslau,  in  1610.  Although  the  disease  had 
been  previously  described,  it  was  not  possible  to  form  any  definite 
opinion  as  to  its  nature  until  Sennert's57  clear  description  appeared  in 
1619.  He  studied  the  affection  in  an  epidemic  at  Wittenberg,  and 
differentiated  it  from  small-pox  and  measles.  He  says:  "Besides  these 
differences,  there  is  another  which,  though  rare,  I  have  often  observed. 
I  have  hitherto  been  doubtful  under  what  name  I  might  distinguish  it 
from  other  diseases,  for,  although,  like  erysipelas,  it  seizes  upon  the 
entire  surface  of  the  body,  yet  I  have  not  seen  it  attack  adults, — which 
often  happens  in  erysipelas, — but  prevails  only  among  infants.  I  pre- 


84  Nola  (Franc.):  "De  epidemics  phlegmone  anginosa,  grassante  Neapoli"  (Venet., 
1610),  4. 

88  Bretonneau  (Pierre):  "Des  Inflammations  spe'ciales  du  tissu  muqueux,  et  en 
particulier  de  la  diphtherite"  (Paris,  1826),  p.  74. 

58  Quoted  by  both  Sennert  and  Most. 

67  Sennert  (David):  "Opera  Omnia"  (Lugduni,  1676),  vol.  vi. 


EARLY    HISTORY.  25 

fer,  therefore,  to  refer  it  to  morbilli,  and  perhaps  it  is  the  disease  which 
Forestus  calls  purpuram  et  rubores  (£pv6ri(j.ara)-  Ingrassias  writes 
that  it  is  called  by  the  Neapolitans  rossaniam  and  rossalia.  The  erup- 
tion consists  of  reddish  maculae,  or,  as  it  were,  little  erysipelatous  spots, 
accompanied  by  a  slight  degree  of  swelling  over  the  whole  body.  Dur- 
ing the  height  of  the  disease,  on  the  fourth  or  fifth  day,  the  entire 
surface  of  the  body  appears  red,  giving  the  appearance  of  a  burn  (quasi 
iffnitum  apparet),  as  if  the  patient  were  laboring  under  universal  ery- 
sipelas. In  the  decline  of  the  disease  the  redness  diminishes,  and  large, 
reddish  spots,  as  in  the  beginning,  appear,  which  disappear  finally  on 
the  seventh  or  ninth  day,  with  scale-like  desquamation  of  epidermis. 
This  disease  is  grave  and  often  fatal,  for  the  redness  is  very  marked. 
The  thirst  is  inextinguishable,  and  frequently  inflammation  of  the 
lungs  (giving  rise  to  cough)  appears,  with  inflammation  of  the  fauces 
and  other  viscera.  Delirium  and  other  threatening  symptoms  are  often 
present.  At  length,  during  the  decline  of  the  disease  the  materies 
morbi  is  transferred  to  the  joints  of  the  extremities  and  excites  pain 
and  redness  as  in  rheumatism.  The  skin  is  shed  in  scales.  Soon  after 
the  feet  swell,  even  to  the  heels  and  soles.  Marked  disturbance  is  like- 
wise observed  in  the  hypochondriac  region.  Respiration  becomes  more 
difficult,  and  at  length  the  abdomen  swells  and  the  sick  are  not  restored 
to  their  former  health  without  much  labor  and  after  a  long  time;  often 
they  may  die."  According  to  Most,58  the  disease  was  also  ob- 
served in  Schlesien  by  Winsler,  of  Brieg,  in  1642,  and  by  Fehr  in  Sax- 
ony in  1652,  from  which  time  it  seems  to  have  been  lost  sight  of  in 
Germany  for  half  a  century. 

The  common  name,  according  to  Storch,58  was  rothen  hund, — i.e., 
red  dog, — from  which  the  Hollanders  derived  their  roothont.  It  may 
be  that  rotheln  is  a  corruption  of  the  same  word,  although  of  this  I  have 
been  unable  to  find  any  mention;  more  probably  it  is  derived  from  roth, 
red,  and  used  in  a  diminutive  sense  (rotheln:  reddish,  pink). 

At  this  time  scarlet  fever  seems  to  have  first  appeared  in  England 
and  later  in  Scotland.59  Severe  epidemics  occurred  in  London  between 
1661  and  1675,  and  it  was  described  by  Sydenham,60  who  called  it  scar- 

68  Most  (George  Frieder):  "Versuch  einer  Kritischen  Bearbeitung  der  Geschicte 
des  Scharlach  fiebers  und  Seiner  Epidemien  von  den  altesten  bis  auf  unsere  Zeiten" 
(Leipzig,  1826). 

B«  Storch  (P.):  "Praktischer  und  Theoretischer  Tractat  vom  Scharlach-Fieber," 
etc.  (Gotha,  1742),  p.  178. 

60Sibbald  (Robert):  "Scotia  Illustrata"  (Edinburgh,  1694).     Part  I,  p.  55. 

81  Sydenham  (Thomas):  "Opera  universa"  (Londini,  1685).  English  translation  by 
Greenhill,  Sydenham  Society,  London,  1844. 


26  THE    ACUTE    EXANTHEMATA. 

latina,  which  name  it  still  bears.  That  Sydenham  was  a  century  in 
advance  of  his  contemporaries  is  evident  from  the  fact  that  Wither- 
ing,01 in  1792,  was  accredited  with  having  differentiated  between  scar- 
latina and  measles. 

Chicken-pox,  naturally,  from  its  mild  nature  attracted  little  at- 
tention, and  aside  from  the  writings  of  Ingrassias  (loc.  cit.)  and  Guito 
Guidi63  (Vidus  Vidius,  1585)  in  Italy,  which  clearly  refer  to  it  under 
the  name  crystalli  (crystals),  it  was  confounded  with  mild  forms  of 
variola. 

From  this  we  may  conclude  that  small-pox  and  possibly  measles 
prevailed  in  China  and  Hindoostan  from  remote  antiquity,  but  did  not 
extend  through  the  western  nations  until  a  later  period.  We  have  no 
positive  proof  that  they  existed  among  western  nations  until  about  the 
fifth  or  sixth  centuries.  It  is  supposed  by  some  that  they  reached  the 
eastern  coast  of  Arabia  by  trading-vessels  from  India,  for  we  first  read 
of  an  epidemic  near  Mecca,  during  the  War  of  the  Elephant  in  the  year 
569,  immediately  before  the  birth  of  Mahomet.  During  the  latter  part 
of  the  sixth  and  the  whole  of  the  seventh  centuries  the  disease  spread 
by  the  Arabians  over  the  countries  of  Asia,  Africa,  and  lands  border- 
ing on  the  Mediterranean  Sea.  It  was  carried  by  the  Saracens  to  Spain, 
Sicily,  Italy,  and  France,  from  which  it  gradually  extended  to  the  north 
of  Europe,  reaching  Switzerland,  Saxony  by  the  way  of  the  Nether- 
lands, and  England  in  the  tenth,  and  probably  the  ninth,  century. 
Finally,  in  the  beginning  of  the  sixteenth  century,  eleven  years  after 
the  death  of  Columbus,  infection  was  transported  by  the  Spaniards  to 
Hispaniola,  and  soon  after  to  Mexico.  At  the  beginning  of  the  six- 
teenth century  it  appeared  along  the  Atlantic  seaboard,  from  which  it 
rapidly  spread  over  the  American  continent.  Strange  as  it  may  appear, 
although  the  principal  diseases  of  the  exanthematous  group  had  re- 
peatedly been  described  and  epidemics  recorded  in  various  countries, 
much  confusion  prevailed  concerning  them  and  their  relation  to  each 
other.  Finally,  a  series  of  epidemics  broke  out  in  London,  which,  like 
Eome  in  the  time  of  Galen,  was  thickly  populated  and  highly  insani- 
tary. The  pestilence  reigned  from  1661  to  1675,  and  was  studied  by 
the  masterly  mind  of  Sydenham,  who  not  only  established  a  clear  dis- 
tinction between  the  various  exanthemata,  but  gave  the  principles  of 
treatment  which  were  both  salutary  and  rational. 


•2  Withering  (William):   "An  Account  of  the  Scarlet  Fever  and  Sore  Throat,   or 
Scarlatina  Anginosa,"  etc.  (London,  1779). 

"Guidi  (Guito)  (or  Vidus  Vidius):   "Ars.  Univ.  Med."  (Venet.,  1596). 


EARLY    HISTORY.  27 

The  classic  production  of  Sydenham  relating  to  small-pox,  meas- 
les, and  scarlet  fever  stands  as  a  living  monument  to  his  memory,  and 
may  be  profitably  consulted  by  the  student  of  to-day. 


CHAPTER  II. 

VARIOLA.64 

(Small-pox;  German,  pocken,  Slattern;  French,  verole,  la 
petite  verole;  Italian,  vajuolo;  Spanish,  viruelas;  Latin,  variola 
vel  febris  variolosa;  Modern  Greek,  Ei>Xo7/a). 

DEFINITION. 

VARIOLA  is  an  acute,  highly-infectious,  and  contagious  disease,65 
met  with  in  all  climates,  and  characterized  by  the  sudden  onset  of  a 
high  fever,  followed,  in  a  few  days,  by  an  eruption  on  the  skin,  which 
is  the  most  constant  and  conspicuous  feature.  It  goes  through  various 
stages  of  development,  from  macules  to  pustules,  and  is  finally  cast  off 
in  the  form  of  variously-sized  crusts,  leaving  more  or  less  cicatrization. 
The  mucous  membranes,  especially  those  exposed  to  the  external  air, 
may  likewise,  though  to  a  less  extent,  be  implicated.  It  is  preceded  and 
accompanied  by  marked  constitutional  symptoms,  which  vary  accord- 
ing to  the  stage  and  severity  of  the  disease.  Like  the  other  exanthem- 
ata, it  has  a  latent  stage,  or  period  of  incubation,  and,  not  infre- 
quently, gives  rise  to  various  complications,  which  co-exist  or  follow  as 
sequela?.  Its  fatality  is  high,  but  varies  greatly  in  different  epidemics. 

VARIETIES. 

As  previously  shown,  variola  at  an  early  period  of  its  history  in- 
cluded the  whole  exanthematous  group.  Morbilli  was  the  first  to  re- 
ceive recognition  as  a  disease  sui  generis,  thus  relieving  variola  of  what 
at  one  time  was  regarded  as  one  of  its  principal  forms.  Although  this 
process  of  elimination,  which  has  gone  on  during  the  centuries,  has 
simplified  the  study  of  the  disease,  yet  it  cannot  be  considered  wholly 
accomplished,  for  by  some  writers  varicella  is  still  treated  of  as  a  variety 
of  small-pox.66  It  is  likewise  of  interest  to  note,  in  this  connection, 
that  Chinese  authors,  with  their  accustomed  tendency  to  detail,  de- 
scribe as  many  as  forty  varieties  of  the  latter  disease.  However,  as 

84  For  derivation  of  these  words  see  pages  16  and  17. 

w  In  this  work  a  distinction  is  made  between  contagion  and  infection.  The  former 
relates  to  personal  touch  or  contact,  from  contingere,  to  touch;  contagio,  touching,  con- 
tact. Infection  refers  to  diffusion  or  mixing,  from  inflcere,  to  put  in,  to  mix,  to  per- 
meate. 

98  Among  whom  may  be  mentioned  Kaposi  and  Kassowitz. 

(28) 


VARIOLA.  29 

small-pox  is  subject  to  marked  variations  in  appearance,  course,  and 
severity,  it  becomes  necessary,  in  order  to  obtain  a  clear  conception  of 
the  disease,  to  recognize  certain  types,  of  which  there  are  three:  the 
natural,  the  hcemorrhagic,  and  the  modified,  or  anomalous. 

The  first  type  is  the  regular,  or  normal,  form  (variola  vera),  which 
is  characterized  by  a  strong  tendency  to  follow  a  uniform  course,  and 
will  be  treated  of  as  the  ideal  from  which  other  types  and  minor  clinical 
forms  proceed. 

Again,  for  convenience  of  description,  rather  than  from  clearly 
defined  pathological  distinctions,  it  is  customary  to  recognize  certain 
clinical  variations,  which  may  be  regarded  as  subdivisions,  or  minor 
clinical  forms.  Thus,  in  the  true  small-pox,  or  variola  vera,  they  relate 
mainly  to  the  distribution  of  the  eruption,  which  may  be  discrete  (from 
the  Latin,  discernere,  to  separate),  when  the  lesions  are  sparsely  scat- 
tered over  the  body;  or  confluent  (confluere,  to  flow  together),  when  the 
lesions  merge,  forming  large,  blister-like  areas.  Again,  the  eruption 
may  be  confluent  on  certain  parts  and  discrete  on  others,  in  which  case 
it  is  sometimes  spoken  of  as  semiconfluent  small-pox.  Finally,  a  con- 
dition is  sometimes,  though  rarely,  observed  in  which  the  lesions  show 
a  marked  tendency  to  form  groups  or  clusters  on  various  parts  of  the 
body,  to  which  the  name  corymbose  has  been  applied. 

The  second  type  is  the  most  striking  of  all  in  appearance,  as  well 
as  the  most  fatal.  It  is  called  hsmorrhagic  small-pox,  or  variola  nigrce 
(Sydenham),  and  presents  itself  under  three  clinical  forms:  the  pur- 
puric,  the  haemorrhagic,  and  the  exudative,  or  secondary.  The  first  is 
characterized  by  the  early  appearance  of  lentil-sized,  dark-bluish  ex- 
travasations of  blood  into  the  skin  and  mucous  membranes  even  before 
the  true  eruption  of  variola  appears.  The  second  form  appears  at  a 
later  stage  of  the  disease,  extravasation  taking  place  directly  into  the 
pocks,  giving  them  a  dark-bluish  color;,  less  frequently  and  to  a  less 
extent  the  intervening  skin  becomes  involved.  As  desiccation  super- 
venes, the  cutaneous  lesions  are  transformed  into  thick,  blackish  crusts; 
hence  commonly  called  black  small-pox.  These  two  forms  are  regarded 
by  most  recent  writers  as  different  degrees  of  the  same  condition.  The 
third  clinical  form,  which  may  be  called  the  exudative,  or  secondary,  is 
quite  distinct  from  the  first  two,  and  is  usually  seen  on  the  feet  and 
legs  of  patients  who  have  been  allowed  to  walk  about  during  the  course 
of  the  disease. 

Finally,  the  third  type  includes  those  cases  in  which  the  individual 
susceptibility  to  the  influence  of  the  variola  poison  is  lessened,  either 


30  THE   ACUTE    EXANTHEMATA. 

by  vaccination,  a  previous  attack  of  variola,  or  a  natural  insuscepti- 
bility, giving  rise  to  a  modified,  or  what  is  sometimes  spoken  of  as 
spurious,  small-pox.  In  other  cases  the  course  of  the  disease,  as  well 
as  the  development  of  the  pocks,  may  be  interrupted,  giving  rise  to  cer- 
tain other  anomalies  of  less  importance,  with  which  we  will  conclude 
the  clinical  description.  From  these  three  types  and  less  distinctive 
clinical  forms  many  deviations  occur,  and  the  line  of  demarkation  is 
not  always  clearly  drawn  between  them. 

That  we  may  obtain  a  clear  conception  of  the  disease  we  will  first 
consider  what  may  be  termed  its  normal  or  regular  course,  when:  (a) 
of  moderate  severity  [discrete  form] ;  (&)  though  severe,  yet  not  neces- 
sarily fatal  [confluent  form]. 


VAEIOLA  VERA. 

(Natural  or  true  small-pox,  the  normal  course  of  small-pox, 
variola  vera  regularis.) 

SYMPTOMATOLOGY. 

The  clinical  description  of  variola  m,ay  be  conveniently  divided, 
first,  into  those  symptoms  which  apply  to  the  disease  in  general;  sec- 
ond, those  which  are  met  with  only  in  certain  types  of  the  disease.  The 
former  will  be  considered  under  variola  vera,  while  the  latter  pertain 
to  the  haemorrhagic  and  modified  forms.  The  symptoms  are  further 
divided  into  groups  which  appear  in  regular  order  and  are  denominated 
stages,  of  which  there  are  five,  as  follows:  Incubation;  initial  or  stage 
of  invasion;  eruption;  maturation,  sometimes  called  stage  of  secondary 
fever;  and  desiccation  or  desquamation. 

(A)  DISCRETE  FORM  (^Variola  Discreta  vel  Distincta). 

As  better  hygienic  measures  obtain  it  may  well  be  that  small- 
pox, like  other  pestilential  diseases,  assumes  a  milder  and  less  fatal 
character.  Although  this  supposition  cannot  be  readily  verified, 
yet  it  is  rendered  highly  plausible  when  we  consider  the  course  and 
fatality  of  the  affection  among  various  races  and  in  various  communi- 
ties in  which  the  conditions  pertaining  to  the  general  health  are  known. 
This  likewise,  to  a  certain  extent,  explains  why  the  so-called  malignant 
small-pox  is  now  less  commonly  met  with  in  well-regulated  cities  than 
in  former  times. 


VARIOLA.  31 

PERIOD  OF  INCUBATION. — The  latent  period  or  stage  of  incubation 
of  small-pox,  in  most  instances,  is  fairly  constant,  being  from  twelve  to 
thirteen  days  from  the  time  of  exposure,  or  reception  into  the  system  of 
the  contagium,  to  the  first  appearance  of  the  prodromal  symptoms. 
From  observations  made  in  the  Cleveland  Detention  Hospital  it  seems 
highly  probable  that  the  duration  of  the  incubation  period,  or 
latent  stage,  depends  largely  either  on  the  severity  of  the  poison  or  on 
the  susceptibility  of  the  person  attacked.  Thus,  in  a  mild  form,  it  may 
be  delayed  one  or  two  days,  while  in  severe  and  fatal  cases  it  appears 
promptly  on  the  twelfth  day. 

In  an  observation  of  1034  cases  Curschmann67  was  able  in  10  cases 
only  to  ascertain  with  tolerable  accuracy  the  length  of  the  latent  stage. 
This  can  be  determined  when  it  is  positively  known  that  the  patient 
has  been  exposed  but  once  and  for  a  short  time.  In  these  10  cases  he 
found  the  initial  stage  of  variola  vera  to  be  from  10  to  13  days,  less 
frequently  14  days,  and  still  less  frequently  8  to  10  days.  In  an  exam- 
ination of  1000  cases  with  special  reference  to  the  prodromal  symptoms 
he  was  able  to  observe  in  11  cases,  or  about  1  per  cent.,  certain  dis- 
turbances during  this  stage,  although  they  were  not  distinctive  nor  of 
prognostic  significance.  The  stage  of  incubation  is  said  to  be  some- 
what shorter  in  hot  countries.  During  this  time  no  apparent  change 
takes  place  in  the  general  health,  although  sometimes  there  is  a  feeling 
of  malaise,  or  the  patient  may  complain  of  having  taken  a  cold,  and, 
while  we  know  that  the  virus  is  not  entirely  inactive  during  this  stage, 
yet,  as  a  rule,  no  effect  is  apparent,  either  to  the  patient  or  his  phy- 
sician. 

ACTUAL   ATTACK. 

THE  INITIAL  STAGE  (Stadium  Prodromorum). — The  onset  of  the 
disease  is  sudden,  and  is  characterized  by  the  violence  of  the  various 
symptoms,  and  the  rapidity  with  which  they  appear.  A  severe  chill  or 
repeated  rigors,  followed  by  a  rise  of  temperature,  dizziness,  nausea,  and 
vomiting,  are  the  usual  symptoms  at  first  observed.  Furthermore,  there 
is  a  general  feeling  of  discomfort,  with  pains  and  aches  in  various  parts 
of  the  body,  most  notably  in  the  lower  part  of  the  back,  corresponding 
to  the  lower  dorsal,  lumbar,  and  sacral  regions.  This  symptom  has  long 
been  noted  as  a  conspicuous  feature  of  the  disease,  and  the  ancients, 
whose  knowledge  of  human  anatomy  was  somewhat  defective,  attributed 


87  Curschmann  (H.):  "Small-pox"  in  von  Ziemssen's  "Cyclopaedia  of  the  Practice 
of  Medicine"   (New  York,  1875),  vol.  ii,  p.  341. 


32  THE    ACUTE    EXANTHEMATA. 

it  to  an  "ebullition  in  the  great  dorsal  vein,"  while  modern  pathologists 
regard  it  as  a  congestion  of  the  spinal  cord.  This  striking  symptom  is 
not  always  present.  Curschmann  observed  it  in  about  60  per  cent,  of 
his  cases,  and  in  30  per  cent,  it  was  sufficiently  severe  to  be  voluntarily 
complained  of.  According  to  the  same  author,  it  is  more  constant  in 
variola  vera  and  in  violent  or  hsemorrhagic  cases  than  in  the  milder 
forms  of  small-pox.  This  symptom  usually  appears  at  the  commence- 
ment of  the  initial  stage;  sometimes  it  precedes,  at  other  times  it  fol- 
lows, the  chill,  and,  as  a  rule,  continues  to  the  outbreak  of  the  eruption. 
At  other  times  a  severe,  though  undefined,  sense  of  illness  is  complained 
of. 

Severe  frontal  headache  is  another  symptom  rarely  absent  at  this 
time.  Like  the  backache,  it  usually  accompanies  the  chill  or  comes  on 
soon  after,  and  continues  with  more  or  less  severity  during  the  initial 
stage.  It  has  been  likened  by  patients  to  the  sensation  of  a  band  drawn 
tightly  about  the  head,  the  pains  increasing  with  every  pulsation.  The 
only  febrile  condition  with  which  it  is  comparable  is  the  onset  of  cere- 
bral meningitis. 

Sometimes  there  is  aching  of  the  long  bones,  especially  at  the 
joints,  which  is  variously  described  as  twisting,  or  wrenching,  and  is 
not  infrequently  referred  to  some  supposed  injury  received,  or  mis- 
taken for  articular  rheumatism.  This  is  especially  so  in  sporadic  cases, 
or  in  those  which  occur  at  the  beginning  of  an  epidemic.  Epigastric 
pain  is  almost  always  present  and  is  not  infrequently  of  great  severity 
It  has  been  mistaken  for  that  due  to  the  ingestion  of  toxic  substances. 
Moreover,  there  is  loss  of  appetite,  with  great  thirst;  the  tongue  is 
furred  in  the  centre  and  red  at  the  point  and  margins;  the  breath  is 
foetid  and  the  lips  are  parched.  Constipation  is  almost  always  present, 
and  continues  during  the  course  of  the  disease,  often  requiring  thera- 
peutic interference.  Diarrhoea  is  sometimes  -met  with  in  children. 
Epistaxis  is  not  uncommon.  In  women  the  menstrual  flow  is  usually 
established  even  between  the  periods.  When  pregnancy  exists  the  lum- 
bar pains  are  often  regarded  as  symptoms  of  premature  labor. 

During  the  first  day  the  temperature  rises  to  102°  or  103°  F.,  with- 
out remission  on  the  following  morning,  and  toward  the  evening  of  the 
second  day  104°  F.  (40°  C.)  or  in  more  severe  cases  105°  F.  (40.5°  C.) 
may  be  reached.  The  highest  temperature  may  be  observed  just  pre- 
ceding the  eruption,  and  usually  on  the  evening  of  the  third  day  of  the 
disease.  Few  febrile  diseases  present  the  sudden  rise  of  temperature 
which  takes  place  in  variola.  In  mild  cases  it  continues  until  the  erup- 


VARIOLA.  33 

tion  appears,  when  its  decline  is  equally  rapid.  In  severer  forms  this 
amelioration  of  the  fever  is  slower,  more  irregular,  and  the  temperature 
during  this  stage  seldom  returns  to  the  normal. 

The  pulse  in  robust  subjects,  especially  in  men,  is  full  and  tense, 
and  ranges  in  frequency  from  100  to  120  beats  to  the  minute.  It  may 
be  remarked  that  its  frequency  corresponds,  in  the  main,  to  the  eleva- 
tion of  the  temperature.  In  children  the  pulse-rate  is  usually  between 
130  and  160.  In  women  and  delicate  persons  it  varies  from  120  to  140, 
is  more  compressible,  and  is  sometimes  dicrotic,  as  in  the  low  fevers. 

The  respiration  is  short  and  labored,  and  always  of  increased  fre- 
quency. As  no  changes  can  be  detected  in  the  respiratory  or  circula- 
tory organs  at  this  time,  Curschmann  attributes  these  symptoms  to  the 
irritating  effect  of  the  febrile  heat  upon  the  respiratory  centres.  Con- 
gestion of  the  mucous  membranes  of  the  fauces  and  the  upper  air- 
passages,  less  frequently  coryza  and  congestion  of  the  conjunctiva,  may 
precede  or  accompany  the  appearance  of  the  eruption.  In  those  who 
have  been  previously  afflicted  with  bronchitis  the  cough  and  expectora- 
tion ordinarily  increase  during  this  stage. 

The  eyes  are  dull,  the  skin  is  dry  and  hot,  the  face  is  flushed,  and 
the  carotids  throb.  The  patient  is  greatly  prostrated,  and,  within  a 
few  hours  after  the  attack,  even  robust  persons  find  difficulty  in  stand- 
ing. If  the  patient  is  observed  in  the  erect  posture  quite  a  different 
picture  presents  itself.  Instead  of  the  throbbing  carotids  and  full, 
flushed  face  the  features  are  blanched  and  expressionless.  Great  dizzi- 
ness is  complained  of,  with  coldness  of  the  hands  and  feet.  The  pulse, 
instead  of  being  full  and  bounding,  as  is  usually  encountered  in  the 
recumbent  position,  is  now  small  and  extremely  frequent.  These  symp- 
toms are,  however,  in  proportion  to  the  'severity  of  the  disease,  and 
correspond  to  the  degree  of  fever.  As  a  rule,  the  pulse-line  corresponds 
to  that  of  the  temperature,  the  two  curves  running  parallel. 

The  nerve-centres  are  usually  impressed  by  the  variolous  poison, 
and  toward  the  evening  of  the  second  or  third  day  the  speech  is  often 
incoherent,  and  the  mind  wanders.  Nearly  all  suffer  from  sleepless- 
ness and  great  disquietude. 

In  children  convulsive  movements  are  often  seen,  varying  in  de- 
gree from  a  sudden  starting  up  or  grinding  of  the  teeth  to  actual  con- 
vulsions. One  case  occurred  during  the  winter  of  1898-99  in  which 
severe  paroxysms  were  observed  in  a  girl,  aged  twelve,  who  subsequently 
developed  a  severe,  though  discrete,  small-pox,  with  a  favorable  ter- 
mination. Sydenham  (op.  cit.)  regarded  this  as  occurring  more  fre- 


34  THE   ACUTE    EXANTHEMATA. 

quently  in  small-pox  than  in  the  other  exanthemata,  and  Trousseau68 
speaks  of  it  as  a  symptom  of  diagnostic  value. 

During  the  initial  stage  the  urine  does  not  present  any  character- 
istic features.  It  is  usually  high  colored  and  concentrated,  according 
to  the  degree  of  fever.  Urea  and  the  urates,  as  well  as  the  sulphates, 
are  increased.  The  chlorides  are  usually  diminished,  as  in  other  febrile 
conditions.  Creatin,  xanthin,  and  tyrosin  may  also  be  present.  In 
severe  cases  a  trace  of  albumin  may  not  infrequently  be  detected,  and 
in  hsemorrhagic  small-pox  it  is  seldom  absent,  even  at  an  early  stage. 
An  abundance  of  albumin  is  looked  upon  as  an  unfavorable  prognostic 
symptom. 

During  the  stage  of  invasion,  usually  on  the  second  day,  there 
sometimes  appears  what  is  termed  a  prodromal  rash  (erythema  vari- 
olosum).  This  is  subject  to  great  variations  in  appearance  and  dis- 
tribution, and  is  more  frequently  met  with  in  some  epidemics  than  in 
others.  In  rare  instances  it  precedes  the  chill  and  is  the  first  symptom 
to  appear.  Furthermore,  it  may  be  limited  to  certain  regions  of  the 
body  (Hebra),  or  it  may  be  widely  diffused  (Curschmann).  Again,  it 
may  be  either  diffused,  as  in  scarlatina,  or  blotchy,  as  in  measles,  and 
not  infrequently  it  is  mistaken  for  one  or  the  other  of  these  diseases. 
The  regions  most  frequently  involved  in  the  prodromal  eruption  are 
the  lower  part  of  the  abdomen  and  inner  surface  of  the  thighs.  Neither 
the  macular  nor  the  diffuse  form  evinces  any  marked  preference  for 
particular  regions,  but  often  spreads  over  the  greater  part  of  the  body. 
When  the  erythema  is  localized,  it  is  usually  seen  on  the  extensor  sur- 
face of  the  extremities,  especially  over  the  joints,  generally  appearing 
in  the  form  of  a  streak  extending  from  the  ankle  upward,  invading  the 
skin  over  the  extensor  hallucis  longus  muscle.  In  women  there  is  often 
seen  a  macular  erythema  around  the  nipples  alone.  This  rash,  al- 
though of  variable  duration,  is  evanescent,  and  usually  fades  away  in 
from  twelve  to  twenty-four  hours,  and  before  the  true  eruption  of 
small-pox  appears.  It  may,  however,  be  delayed  until  after  the  first 
appearance  of  the  eruption  on  the  face,  but  fades  before  the  trunk  and 
extremities  are  attacked,  leaving  a  slightly  pigmented  furfuraceous 
surface.  From  this  it  may  be  inferred  that  the  prodromal  rash  is  in- 
constant, and,  when  present,  is  subject  to  great  variability,  both  as  to 
appearance  and  distribution.  The  importance,  however,  of  bearing  the 
subject  in  mind  cannot  be  too  strongly  urged,  lest  its  appearance  lead  to 


88  Trousseau:   "Clinical  Medicine"   (Philadelphia  Edition,  1873),  vol.   i,  p.  65. 


VARIOLA.  35 

an  error  in  diagnosis.  According  to  Hebra60  and  Trousseau  (op.  cit.}, 
the  regions  involved  in  the  prodromal  rash  remain  exempt  from  the 
actual  small-pox  eruption,  while  Curschmann  says  the  variola  lesions 
rarely  ever  appear  on  the  lower  part  of  the  abdomen  and  inner  surface 
of  the  thighs,  even  when  the  prodromal  rash  is  absent.  While  not 
wholly  agreeing  with  the  latter,  extended  observation  leads  the  writer 
to  believe  that  the  lesions,  though  not  entirely  absent,  show  little  tend- 
ency to  group  themselves  or  to  become  confluent  in  the  parts  forming 
the  crural  triangle  of  Simon.70  Furthermore,  an  extensive  erythem- 
atous  rash  is  usually  followed  by  a  discrete  variola  eruption,  and  when 
present  is  of  considerable  prognostic  value.  Finally,  it  must  be  borne 
in  mind  that  the  initial  stage  is  subject  to  certain  modifications  accord- 
ing to  the  severity  of  the  disease  and  the  individual  peculiarities,  and 
many  symptoms  here  described  may  vary  in  severity  or  be  wholly  ab- 
sent. In  addition,  it  is  well  to  emphasize  the  fact  that  the  subsequent 
course  of  the  disease  cannot  invariably  be  foretold  from  the  initial 
symptoms. 

THE  ERUPTIVE  STAGE  (Stadium  Eruptionis). — This  usually  takes-, 
place  after  the  third  febrile  exacerbation,  and  is  seen  on  the  morning- 
of  the  fourth  day.  It  is  somewhat  shorter  in  children  than  in  adult& 
and  is  prolonged  in  old  age.  The  eruption  is  first  observed  on  the  face,. 
— the  most  constant  position  being  the  upper  part  of  the  forehead, — 
and  consists  of  pale-red  erythematous  specks,  from  a  pin-head  to  a 
millet-seed  in  size,  which  disappear  on  pressure  or  when  the  patient 
assumes  an  erect  posture.  Within  a  few  hours,  or  it  may  be  simul- 
taneously, deep-pinkish  dots  appear  about  the  nose,  mouth,  chin,  and 
hair  follicles  of  the  scalp.  At  the  end  of,  or  during,  the  first  day  a  faint 
appearance  of  the  eruption  may  be  detected  on  the  hands  and  wrists. 
Occasionally  this  order  is  reversed,  it  first  appearing  on  the  hands  and 
subsequently  on  the  face.  Again,  the  eruption  may  first  show  itself  on 
other  parts  of  the  body.  This  is  notably  the  case  when  patches  of 
eczema,  acne,  or  other  cutaneous  inflammatory  disturbances  exist,  in 
which  case  the  pocks  not  infrequently  appear  first  on  these  areas,  and 
throughout  their  whole  course  show  a  tendency  to  assume  a  confluent 

89  Hebra  (F.):  "Diseases  of  the  Skin,"  New  Sydenham  Society's  transactions  (Loo- 
don,  1866),  vol.  i,  p.  242. 

70  This  space  is  bounded  above  by  an  imaginary  line  drawn  transversely  across  the? 
umbilicus,  which  forms  the  base;  the  sides  are  formed  by  the  lumbar  regions,  and  the* 
apex  is  directed  downward  and  corresponds,  when  the  knees  are  pressed  together,  to» 
a  point  situated  about  two  inches  above  the  patellae.  Simon  (Th.):  "Des  Prodromal! 
exanthem  der  Pocken,"  Archiv  fur  Dermat.  und  Syphilographie,  II  Jahrgang,  S.  34?  e< 
seq. 


36  THE    ACUTE    EXANTHEMATA. 

character,  while  on  the  normal  skin  the  variolous  eruption  may  be  dis- 
crete. Thus,  a  patient  entered  the  Small-pox  Hospital  during  the 
initial  stage  with  a  patch  of  eczema  on  the  leg,  which  became  thickly 
covered  with  the  variola  lesions,  while  the  sound  skin  was  but  dis- 
cretely attacked.  Likewise  the  eruption  tends  to  become  confluent  on 
parts  of  the  body  that  have  been  subjected  to  irritation.  Curschmann 
relates  the  instance  of  a  patient  infested  with  body-lice  in  whom  the 
eruption  appeared  in  the  form  of  streaks,  following  the  nail-marks  and 
resembling  strings  of  pearls,  the  uninjured  parts  having  but  few  variola 
lesions.  From  experiments  he  ascertained  that  the  injury  to  the  skin 
must  precede  the  eruption,  otherwise  no  change  takes  place.  On  the 
contrary,  Hebra  observed  in  ichthyosis  and  prurigo  that  the  eruption 
avoided  the  parts  affected  with  these  diseases,  and  appeared  only  on  the 
normal  skin:  i.e.,  the  flexor  surfaces  of  the  joints.  Stokes71  has  also 
called  attention  to  the  influence  of  the  local  blood-supply  on  the  sub- 
sequent small-pox  eruption.  By  reducing  the  vascularity  of  the  part, 
by  poulticing  or  other  means  of  depletion,  he  was  able  to  restrict  the 
number  of  lesions,  even  in  confluent  cases.  According  to  Marson,72 
the  eruption  is  not  thrown  out  at  random,  but  appears  in  regular  order, 
first  on  the  face  and  scalp  in  groups  of  fours  and  fives,  forming  cres- 
cents, which  sometimes  extend  into  circles;  next  on  the  hands  and 
neck;  then  the  back  and  chest;  and  finally  the  arms  and  legs. 

With  the  first  appearance  of  the  eruption  the  fever  rapidly  sub- 
sides, the  temperature  remaining  normal  in  mild  cases  to  the  end 
of  the  disease  (Variola  benigna).  This  is  of  great  diagnostic  impor- 
tance, as  it  occurs  in  no  other  of  the  exanthemata.  At  other  times,  and 
in  less  favorable  cases,  there  is  a  slight  rise  in  the  evening  temperature. 
The  pulse  in  uncomplicated  cases  corresponds,  for  the  most  part,  to 
the  temperature,  and  varies  from  90  to  120.  The  r»ains  previously 
complained  of  disappear,  and  sometimes  there  is  a  relish  for  food,  and 
the  patient  imagines  himself  well-nigh  recovered.  This  is  usually  de- 
pendent upon  the  amount  of  fever.  With  the  disappearance  of  sickness 
and  pain  the  mind  regains  its  normal  condition  and  refreshing  sleep 
is  gradually  obtained.  Profuse  perspiration  is  often  seen  during  the 
eruptive  stage.  It  varies  greatly  in  different  epidemics.  It  was  a  con- 
spicuous feature  during  the  epidemic  of  1898-1901  in  Cleveland. 
Trousseau  regarded  it  as  a  favorable  symptom. 

On  the  morning  of  the  second  day  of  the  eruption  the  reddish 

71  Stokes  (William):  Dublin  Jour,  of  Med.  Sci.,  vol.  liii,  p.  9. 

"Marson  (J.  F.):   Reynolds's  "System  of  Medicine"  (London,  1870),  vol.   i,  p.  226. 


PLATE  II. 


Variola,    showing   Hard    Papular   Eruption   on   the    Morning  of  the   Second    Day. 


PLATE  III. 


PLATE  III. 


Variola   in   the   Negro:     Papular   Stage   as   Seen    Late   on   Second    Day  of   Eruption 


PLATE  IV. 


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VARIOLA.  37 

specks  or  dots  in  the  skin  of  the  face  are  found  to  be  developed  into 
more  prominent  papules,  somewhat  resembling  flea-bites,  and  accom- 
panied by  a  slight  sensation  of  burning  and  itching.  They  soon — 
sometimes  during  the  first  day — begin  to  assume  an  indurated  con- 
dition, which  gives  to  the  surface  a  hard,  roughened  feel  when  the 
hand  is  drawn  over  the  skin.  During  the  second  day  of  the  eruption 
and  sixth  of  the  disease  the  lesions  on  the  face  are  slightly  conical, 
and  to  the  touch  may  be  likened  to  duckshot  imbedded  in  the  skin. 
(Plate  II.)  This  feature  is  usually  well  marked  and  of  characteristic 
significance.  In  the  colored  race  the  lesions  at  this  time  present  a 
whitish  appearance.  (Plate  III.)  With  the  exception  of  the  hands 
and  forearms,  the  eruption  appears  from  .one  to  two  days  later  on  the 
trunk  and  extremities  than  on  the  face  and  scalp,  and  the  feet  are  the 
last  to  be  involved.  This  order  continues  throughout  the  whole  course 
of  the  eruption.  After  the  papules  have  attained  the  size  of  a  small 
pea  or  lentil  on  the  third  day,  their  summits  gradually  assume  a  trans- 
lucent, glazed  appearance,  which  indicates  the  formation  of  a  vesicle. 
As  this  enlarges  a  central  depression,  or  umbilication,  first  takes  place, 
which  is  looked  upon  as  characteristic  of  the  small-pox  lesion.  (Plate 
IV.)  It  is  not  always  present,  and  when  seen  it  usually  disappears  with 
the  full  development  of  the  pustules.  At  this  time,  if  punctured,  a 
small  amount  of  slightly  mucilaginous  serum  exudes.  The  vesicles  thus 
formed  never  present  the  prominent  appearance  seen  in  the  more  su- 
perficial lesions  of  varicella.  During  the  fourth  and  fifth  days  of  the 
eruption  the  vesicles  continue  to  increase  in  size,  and  the  glazed  top 
gradually  assumes  an  opaque,  whitish  color.  Umbilication  at  this  time 
is  usually  well  marked. 

The  eruption  is  not  limited  to  the  skin,  but  sometimes  appears 
simultaneously  on  the  contiguous  mucous  membranes  at  the  various 
orifices  .of  the  body.  The  buccal  cavity,  nares,  and  throat  seldom  en- 
tirely escape,  and  pain,  with  difficulty  of  breathing  and  swallowing,  is 
often  a  serious  condition  to  encounter. 

STAGE  OF  SUPPURATION  (Stadium  Floritioms). — On  the  sixth  day 
of  the  eruption  and  tenth  day  of  the  disease  the  lesions  have  usually 
assumed  a  yellowish  tint,  from  the  admixture  of  pus-cells  or  polymor- 
phonuclear  leucocytes,  resembling  wash-leather  or  rich  cream.  The 
pocks  are  about  a  centimetre  in  diameter,  and  project  with  tense  walls 
above  the  level  of  the  skin,  excepting  on  the  palms  and  soles,  where  they 
are  bound  down  by  the  unyielding  epidermis.  Sometimes  the  integu- 
ment of  the  face  presents  an  erysipelatous  redness;  it  is  usually  swollen 


38  THE    ACUTE    EXANTHEMATA. 

even  when  the  pocks  are  few.  (Plate  IV.)  This,  however,  is  of  short 
duration,  and  the  skin  between  the  lesions,  in  the  discrete  variety,  soon 
returns  to  its  normal  color,  when  an  erythematous  halo  may  be  seen  to 
surround  the  pustules.  There  is  occasionally  a  slight  rise  of  tempera- 
ture with  the  full  development  of  the  eruption  (suppurative  fever),  due 
to  absorption  of  pus.  Its  severity  is  not  always  dependent  on  the  num- 
ber of  pocks,  but  may  be  the  outcome  of  individual  peculiarities,  as 
pointed  out  by  Curschmann,  being  most  frequently  seen  in  delicate 
persons,  women  and  children.  (Plate  V.) 

On  the  trunk,  arms,  and  legs  little  or  no  oedema  is  present,  and 
the  individual  lesions,  surrounded  with  a  narrow,  though  intense,  ery- 
thematous ring, — which  begins  with  the  formation  of  the  pustules, — 
can  be  clearly  seen.  The  pustules  attain  their  full  development  and 
are  of  a  yellow  color  on  the  eighth  day  of  the  eruption  and  twelfth  of 
the  disease.  (Plate  VI.)  During  one  or  two  days  thereafter  but  little 
change  can  be  detected,  but  on  the  eleventh  or  twelfth  day  of  the  erup- 
tion the  first  indication  of  subsidence  may  be  seen. 

DECLINE. 

STAGE  OF  DESICCATION  (Stadium  Exswcatwnis,  sen  Decrusta- 
tionis). — The  last  stage  of  the  eruption  begins  gradually  on  or  about 
the  twelfth  day  with  rupture  of  the  pustule-walls,  thus  allowing  an 
oozing  of  their  contents,  or  by  their  absorption  or  evaporation,  which 
constitutes  th'e  stage  of  desiccation.  This  process  takes  place  first  in 
the  centre  of  the  pustule,  corresponding  to  the  site  of  umbilication, 
forming  a  brownish  scab,  which  is  at  first  firmly  adherent.  Finally, 
the  whole  lesion  becomes  transformed  into  a  dark-brown  or  blackish 
crust,  which  gives  to  the  body  the  appearance  of  having  been  bespat- 
tered with  mire.  (Plate  XIII.) 

The  hands  follow  in  regular  order,  while  on  the  face  and  scalp  the 
crusts  gradually  fall  off  in  from  three  to  six  days,  leaving  slightly 
raised  maculae  of  a  violaceous  or  reddish  hue.  Within  two  or  three  days 
the  dark  crusts,  corresponding  to  the  central  depressions,  are  seen  on 
the  body,  likewise  following  the  order  of  invasion.  It  may  be  remarked 
that  desiccation  on  the  palms  and  soles  begins  sooner,  and  lasts  longer, 
than  on  other  parts  of  the  extremities.  (Plate  XIV.)  The  separation 
of  crusts  takes  place  between  the  sixteenth  and  twenty-first  days.  As 
the  crusts  drop  off  a  furfuraceous  desquamation  takes  place  for  a  period 
varying  from  one  to  two  weeks,  after  which,  if  no  complications  exist, 
the  patient  may  be  allowed  to  go  at  large. 


PLATE  V. 


PLATE  VI. 


VARIOLA.  39 

Not  infrequently  the  stage  of  desiccation  is  complicated  by  the 
local  infection  of  the  ordinary  pus-cocci.     In  certain  cases  soon  after 
desiccation  begins  the  variola  lesions  on  the  backs  of  the  hands  and 
dorsal  surface  of  the  feet  become  flaccid,  lose  their  yellow  color,  and 
extend  at  the  margins  by  a  serous  undermining  of  the  epidermis.    Not 
infrequently  bullae  of  various  sizes  form,  or  there  may  be  an  accumula- 
tion of  a  viscid,  slightly  opaque  fluid  at  the  periphery,  which  forms  an 
elevated  rim,  surrounding  a  depressed  area  of  shriveled,  sometimes 
shredded,  epidermis,  in  the  centre  of  which  a  dark.,  adherent  crust, 
corresponding  to  the  original  pock,  may  be  seen.     (Plate  VII.)     The 
bullous  process  may  extend  to  the  forearms  and  legs,  but  only  in  rare 
instances  does  it  become  more  general.    It  has  been  observed  most  fre- 
quently in  severe  cases  of  discrete  variola,  and  often  produces  more  or 
less  extensive  blister-like  areas,  from  blending  of  the  lesions,  as  in  the 
confluent  form.    The  eruption  presents  a  striking  appearance,  and  its 
presence  may  lead  to  serious  error  in  diagnosis.    The  condition  is  iden- 
tical with  that  observed  in  impetigo,  especially  the  bullous  form,  which 
was  observed  so  plentifully  among  the  Northern  soldiers  who  took 
part  in  the  late  Spanish-American  War.73     Nor  are  the  conditions 
which  occasion  it  wholly  dissimilar,  for  in  impetigo  bullosa  we  found 
that  the  ordinary  pus-organisms — notably  the  staphylococcus  pyogenes 
aureus,  albus,  and  to  a  less  extent  citreus — thrived  and  produced  cuta- 
neous lesions  which  differed  in  clinical  significance  under  the  favorable 
conditions  for  the  development  of  extraneous  organisms,  and  the  feeble 
power  of  the  tissues  in  resisting  them,  which  likewise  accounts  for  the 
various  coccogenous  affections  met  with  at  this  time.     In  addition  to 
the  bullous  eruption,  as  desiccation  proceeds,  boils,  deep  phlegmonous 
abscesses,  and,  on  the  legs,  ecthymatous  crusts,  are  the  most  frequent 
complications  of  variola.    More  rarely,  erysipelas  occurs  from  inocula- 
tion of  the  streptococcus  of  Fehleisen.    Finally,  the  absorption  of  sep- 
tic material  may  further  retard  convalescence  and  give  rise  to  a  general 
erythema  and  constitutional  symptoms  similar  to  those  met  with  in 
septic  conditions  of  other  diseases. 

(B)  THE  CONFLUENT  FORM  (Variola  Confluens). 

This  differs  from  the  preceding  variety  mainly  in  the  severity  of 
its  symptoms,  the  extent  of  the  eruption,  and  in  the  fatality  of  the  dis- 


73  The  author:  "Impetigo:  its  Clinical  Forms,  including  Ecthyma  and  the  so-called 
Pemphigus  Contagiosus,"  Cleveland  Jour,  of  Med.,  December,  1898. 


40  THE   ACUTE    EXANTHEMATA. 

ease.  In  former  times  confluent  small-pox  was  far  more  common  than 
at  present,  although  in  certain  communities  and  in  certain  epidemics  it 
is  still  the  prevailing  form.  Even  when  the  death-rate  is  low,  if  the 
disease  be  not  checked,  certain  cases  present  themselves  in  which  large 
areas  of  skin  are  entirely  covered  with  the  eruption.  Confluent  small- 
pox is  one  of  the  most  fatal  and  loathsome  of  epidemic  diseases,  and 
millions  of  lives  have  been  sacrificed  to  its  sway.  There  is  nothing 
peculiar  in  the  period  of  incubation. 

ACTUAL   ATTACK. 

INITIAL  STAGE. — As  previously  stated,  the  degree  of  systemic 
intoxication,  or  severity  of  the  poison,  may  sometimes  be  observed,  even 
during  the  initial  stage.  This,  however,  is  not  infallible,  for  numerous 
exceptions  occur.  It  may  be  stated,  however,  that  in  confluent  variola 
the  initial  symptoms  are  never  of  a  mild  character.  For  the  most  part, 
then,  the  symptoms  are  similar  to  those  already  described,  excepting 
that  they  tend  to  greater  regularity  and  are  more  uniformly  severe. 
The  nerve-centres  are  accordingly  more  profoundly  impressed,  and  vio- 
lent delirium  in  adults  and  convulsions  in  children  are  not  infrequently 
seen.  The  former  oftentimes  partakes  of  a  boisterous  nature,  and  phys- 
ical restraint  is  sometimes  necessary.  In  children  epileptiform  attacks 
may  be  well  marked.  The  fever  not  infrequently  rises  to  105°  F. 
(40.4°  C.)  or  even  higher,  and  vomiting  is  usually  more  persistent  than 
in  the  milder  forms.  This  latter  sometimes  continues  during  the  whole 
initial  stage.  At  other  times  it  appears  just  before  the  eruption,  in 
which  case  the  prognosis  is  rendered  less  favorable  than  when  it  appears 
at  the  onset.  Great  prostration  is  likewise  always  observed,  and  the 
patient  may  die  from  collapse  at  this  time  (variola  sine  eruptione).  The 
prodromal  eruption  is  seldom  seen  in  this  form. 

ERUPTIVE  STAGE. — The  eruption  appears  sooner  than  in  the  milder 
form  heretofore  observed,  occurring,  for  the  most  part,  on  the  third  day. 
Less  frequently  it  occurs  on  the  morning  preceding  this,  or  second  day. 
The  appearance  of  the  true  eruption  may  be  similar  to  that  of  the 
discrete  form,  and  even  at  this  time  one  may  not  be  able  to  distinguish 
between  them.  The  regions  first  attacked  likewise  correspond,  but  in 
confluent  variola  new  erythematous  specks  appear  during  the  first  and 
second  days  between  the  lesions  previously  thrown  out,  until  the 
whole  surface  of  the  face  is  thickly  covered,  as  in  Plate  VIII.  Even 
yet  the  papules  may  be  clearly  defined,  and  show  little  or  no  tendency 


PLATE  VII. 


PLATE  VIII. 


VARIOLA.  41 

to  merge.  Frequently,  however,  the  confluent  nature  may  be  detected 
from  the  first,  and  during  the  first  day  the  number  of  lesions  may 
be  complete.  The  skin  is  swollen,  and  a  deep  erythematous  color 
oftentimes  gives  the  appearance  of  severe  erysipelas.  The  skin  is  more 
widely  cedematous  than  in  the  latter  disease,  and  on  the  affected  surface 
numerous  small  vesicles  may  soon  be  detected,  giving  the  appearance 
of  a  burn.  The  scalp  is  swollen  and  thickly  set  with  pocks,  which,  on 
account  of  their  unyielding  base,  are  extremely  painful.  The  hands, 
forearms,  trunk,  and  legs  are,  in  turn,  invaded,  but  far  more  rapidly 
than  in  milder  forms.  (Plate  IX.)  Within  thirty-six  hours  the  full 
quota  of  lesions  is  usually  complete;  in  fact,  instances  are  occasionally 
met  with  in  which  the  eruption  appears  almost  simultaneously  over 
the  whole  body.  The  lesions  are  red  and  angry  and  often  show  a  tend- 
ency to  run  together.  The  temperature,  which,  in  the  preceding  or 
discrete  variety  rapidly  fell  to  the  normal  (crisis),  now  not  infrequently 
shows  but  little  change,  although  it  drops  irregularly  as  the  lesions 
develop  (lysis).  Earely  does  it  descend  to  the  normal,  but  more  fre- 
quently there  is  a  slight  evening  rise.  It  may  be  stated  as  a  rule  that 
the  temperature  does  not  fall  below  100°  in  the  morning  and  102°  F. 
(38.8°  C.)  in  the  evening  during  the  whole  course  of  maturation.  As 
pointed  out  by  Wunderlich,74  two  types  of  fever  are  observed  in  variola: 
the  brief,  continuous  fever  of  the  milder  forms,  which  subsides  with 
the  appearance  of  the  eruption  and  seldom  returns  during  the  course 
of  the  disease;  and  the  relapsing  fever,  which  is  characteristic  of  the 
confluent  and  severe  forms  of  variola. 

The  mucous  membranes  likewise  are  red  and  swollen,  and  fre- 
quently dotted  with  reddish  maculae,  which  are  especially  marked  on 
the  fauces,  tongue,  tonsils,  and  inner  surface  of  the  cheeks.  The  nose 
becomes  early  occluded  from  swelling  of  the  mucous  membrane,  and 
the  eyes  are  congested,  with  much  lacrymation  and  photophobia. 
Hearing  may  likewise  be  temporarily  impaired,  and  a  profound  sense 
of  illness  take  possession  of  the  patient. 

With  the  completion  of  vesiculation  the  lesions  enlarge,  come  in 
contact  with  each  other,  and  merge,  forming  large  areas  in  which  the 
epidermis  appears  to  be  raised  into  an  irregular  or  corrugated  surface 
as  if  scalded,  even  before  suppuration  takes  place.  (See  Plate  X.)  The 
trunk  next  follows  in  regular  order,  and,  although  the  eruption  is  less 
abundant,  the  skin  is  more  or  less  thickly  covered,  and  in  many  places 

74  Wunderlich  (C.  A.):  "Das  Verhalten  der  Eigenwarme  in  Krankheiten"  (Leipzig, 
1870),  pp.  322  et  se<7. 


THE    ACUTE    EXANTHEMATA. 


Chart  showing  High  Temperature  and  Marked  Secondary  Fever  in 
a  Case  of  Confluent  Small-pox  terminating  in  Recovery.  (From  One  of 
the  Author's  Patients.) 


PLATE  IX. 


X 


E- 

-T- 


PLATE  X. 


VARIOLA.  43 

the  lesions  run  together.  This  varies  in  degree  in  different  cases. 
Sometimes  large  blister-like  areas  form,  with  great  swelling  of  the  parts 
and  pain,  rendering  the  sufferings  of  the  patient  intolerable.  Great 
oedema,  either  localized  or  general,  accompanies  this  form.  It  is  best 
marked  on  the  face,  which  sometimes  loses  all  semblance  of  humanity. 
The  hands  present  the  same  swollen  appearance;  the  fingers  are  semi- 
flexed,  and  the  slightest  movement  causes  the  sufferer  to  cry  out  with 
pain.  On  the  palms  and  soles  the  pustules  are  always  present,  and, 
as  previously  remarked,  are  of  considerable  diagnostic  value,  being 
rarely  situated  there  in  the  other  exanthemata.  The  feet  are  greatly 
swollen  and  painful,  while  the  legs,  and  less  frequently  the  whole  body, 
partake  of  the  general  oedema,  which  is  proportionate  to  the  confluence 
of  the  eruption.  This  swelling  usually  lasts  from  the  ninth  to  the  thir- 
teenth or  fourteenth  days.  The  great  pain  complained  of  in  the  hands 
and  feet  is  due  to  the  extreme  tension  caused  by  inflammatory  products 
under  the  dense  fascia  of  the  palms  and  soles. 

The  older  authors  attributed  great  prognostic  importance  to  the 
swelling  of  the  hands.  Sydenham  remarks,  in  speaking  of  a  severe  case 
which  he  observed:  "His  only  remaining  hope  being  that  the  swelling 
of  the  hands  may  be  of  such  an  amount  as  to  save  him  from  the  jaws 
of  death.  This  sometimes  takes  place.  The  swelling  of  the  hands  sets 
in  later  than  on  the  face,  and  consequently  lasts  longer." 

On  the  eighth  day  the  lesions  attain  their  maturity,  when  serious 
adynamic  symptoms  not  infrequently  supervene.  (See  Plate  XI.) 
The  breathing,  which  at  the  beginning  of  the  eruptive  stage  became 
easier,  is  again  short  and  labored.  There  is  not  infrequently  a  marked 
rise  of  temperature,  which  is  called  the  secondary  fever.  This  arises 
from  the  absorption  of  septic  material,  and  is  usually  in  proportion  to 
the  extent  of  the  eruption.  It  attains  a  height  of  104°  to  106°,  and 
even  107°  F.  (40°,  41.1°,  41.6°  C.)  has  been  observed.75  It  is  more 
constant  than  in  the  milder  forms,  and  is  usually  preceded  by  a  chill 
and  accompanied  by  great  prostration.  The  pulse,  which  during  the 
initial  fever  was  bounding  and  full,  now  becomes  dicrotic,  compressible, 
and  often  irregular,  indicating  that  the  heart's  action  partakes  of  the 
general  enfeebled  condition.  Diarrhoea  is  often  an  alarming  symptom 
at  this  time,  and  is  especially  common  among  infants,  while  in  adults 
the  bowels  are  throughout  the  whole  course  usually  constipated,  and 
require  therapeutic  measures  for  relief.  It  would  appear  from  the  older 

75  Moore  (J.  W.):  "Small-pox,"  in  "Twentieth  Century  Practice  of  Medicine"  (New 
York,  1898),  vol.  xiii,  p.  428. 


44  THE   ACUTE    EXANTHEMATA. 

authors  that  diarrhoea  was  formerly  far  more  common  in  adults  than 
at  present.  The  mind,  which  partially  regained  its  normal  condition 
upon  the  appearance  of  the  eruption,  again  shows  marked  symptoms 
of  cerebral  implication.  Prolonged  sleeplessness,  low  muttering  speech, 
and  coma  not  infrequently  supervene,  or  the  delirium  may  be  of  a  vio- 
lent nature,  the  patient,  imagining  himself  pursued  by  some  horrible 
apparition,  not  infrequently  escapes  from  all  restraint  and  inflicts  upon 
himself  some  serious  injury.  The  height  of  the  disease  is  attained  be- 
tween the  eighth  and  tenth  day,  and  at  this  time  the  affection  is  most 
fatal.76 

The  mucous  membranes  are  always  involved,  and  while  more  vari- 
ability is  met  with  than  on  the  external  integument  on  account  of  the 
constant  maceration  and  friction  to  which  they  are  subjected,  yet  they 
sometimes  closely  approximate  the  typical  characters  observed  on  the 
skin.  Thus,  in  the  pharynx  and  on  the  tonsils,  lentil-sized,  dark-red- 
dish spots  may  first  be  seen,  which  gradually  become  more  prominent, 
and  sometimes  even  vesicular,  although  when  punctured  no  serum  can 
be  detected.  About  the  seventh  day  of  the  eruption  they  appear  as 
opalescent,  grayish  elevations  upon  a  reddened  base.  Later,  the  epithe- 
lial covering  ruptures,  giving  rise  to  excoriated  and  ulcerated  patches. 
Although  the  soft  palate  in  most  cases  seems  to  be  a  favorite  position 
for  the  eruption,  it  may  attack  almost  exclusively  the  inner  surface  of 
the  cheeks  or  the  tongue,  which  becomes  swollen  and  protrudes  beyond 
the  lips.  A  case  recently  under  observation  at  the  Small-pox  Hospital 
presented  typical,  yellowish  pustules  with  denuded  apices,  each  sur- 
rounded by  a  reddish  base,  which  was  best  marked  on  the  tongue  and, 
to  a  less  extent,  over  the  whole  buccal  mucous  membrane.  In  infants 
this  is  an  alarming  condition,  and,  as  they  are  unable  to  nurse,  death 
from  inanition  is  liable  to  occur.  The  eruption  may  also  extend  to  the 
larynx  and  trachea,  giving  rise  to  hoarseness,  dysphagia,  and  aphonia; 
or  to  the  nare's,  completely  occluding  these  passages.  When  the  tonsils 
are  attacked,  deep  ulcers  and  abscesses  are  often  formed,  accompanied 
or  preceded  by  oedema  of  the  glottis,  rendering  the  situation  critical. 
Epistaxis  is  not  infrequent,  together  with  salivation,  photophobia,  and 
lacrymation.  Salivation  was  regarded  as  of  great  importance  by  the 
older  writers  on  small-pox,  because,  like  the  pustules,  it  was  looked 
upon  as  one  of  nature's  methods  of  eliminating  the  poisonous  humors. 


79  In  an  examination  of  5000  cases  Hebra  (loc.  cit.)  found  that  35  per  cent,  attained 
the  greatest  severity,  as  indicated  by  the  pulse,  on  the  tenth  day. 


PLATE  XI. 


u 


PLATE  XII. 


VARIOLA.  45 

It  is  now  regarded  as  a  reflex,  or  inflammatory,  disturbance  of  the 
salivary  glands  and  possibly  Steno's  duct,  having  no  prognostic  sig- 
nificance, although  causing  much  distress  on  account  of  the  pain  at- 
tending any  attempt  at  deglutition.  For  this  reason  the  saliva  flows 
from  the  open  mouth  in  large  quantities,  and  proves  a  troublesome 
complication.  Wendt77  has  observed  that  the  eruption  sometimes  ex- 
tends to  the  Eustachian  tubes.  The  eruption  is  seen  less  frequently 
on  the  mucous  membranes  of  the  vulva  and  vagina,  as  also  on  the  lower 
part  of  the  rectum.  Like  the  skin  eruption,  it  is  slower  to  appear  and 
more  sparsely  distributed  on  these  parts.  The  urethra  is  very  seldom 
involved.  According  to  Curschmann,  true  pustules  are  never  found  in 
the  stomach  or  intestines,  although  J.  W.  Moore  describes  the  entire 
respiratory  and  digestive  tracts  as  being  thickly  studded  by  the  variola 
eruption,  appearing  as  whitish  or  pearly-gray  ulcerations  upon  a  red- 
dish base.  On  the  mucous  membranes  exposed  to  the  external  air  the 
lesions  are  more  fully  developed,  and  finally  lead  to  abrasions  of  various 
shapes  and  sizes. 

Although  death  may  end  the  sufferings  of  the  patient  at  any  time, 
this  is  considered  the  most  critical  period.  In  unfavorable  cases  the 
pustules  not  infrequently  become  flaccid,  the  face  suddenly  loses  its 
red,  puffy  aspect,  and  the  features  appear  sunken — which  by  older  au- 
thors was  called  "striking  in"  of  the  eruption, — the  pulse  flutters,  coma 
increases,  and  the  patient  expires.  With  this  there  is  usually  a  rapid 
elevation  of  temperature,  which,  as  observed  by  Simon,78  continues  to 
rise  for  an  hour  or  two  after  death.  Within  a  day  or  two,  if  the  patient 
survive,  the  cedema  begins  to  subside,  and  the  redness  of  the  skin  dis- 
appears, excepting  an  erythematous  ring,  or  halo,  which  surrounds  the 
base  of  the  pustules.  This  is  more  pronounced  and  of  a  deeper  color 
than  in  varicella,  and  is  best  seen  on  the  trunk,  legs,  and  arms. 

DECLINE. 

STAGE  OF  DESICCATION. — After  the  eleventh  day  signs  of  sub- 
sidence in  the  eruption  begin  to  appear,  usually  by  resorption,  or  rupt- 
ure of  the  pustules,  the  contents  of  which  on  exposure  to  the  air  rapidly 
undergo  decomposition,  giving  forth  a  most  nauseating  stench,  which 
by  some  is  considered  characteristic  of  the  disease.  As  desiccation  pro- 

77  Wendt:    "Ueber   das    Verhalten    des    Gehororgens    und    Nasenrachenraums    bei 
Variola,"  Archiv  fur  Heilkunde,  B.  13,  S.  118  und  414. 

78  Simon:  In  two  instances  after  death  it  was  110.75°  and  112.1°  F.,  respectively. 
Charite  Annalen,  xii,  B.  5. 


46  THE    ACUTE    EXANTHEMATA. 

ceeds  large  areas  of  blackish  crusts  are  formed,  as  shown  in  Plate  XIII, 
which  restrict  the  movements  of  the  hands  and  feet,  and  give  to  the 
face  the  appearance  of  being  incased  in  a  rough,  blackish  mask.  The 
swelling  gradually  subsides,  while  severe  itching  sets  in  to  further 
harass  the  already-exhausted  sufferer.  Symptoms  of  pyaemia  are  liable 
to  occur  at  this  time,  or  death  may  be  due  to  complications  arising  from 
severe  disturbances  of  the  internal  mucosa?,  giving  rise  to  pneumonia, 
pleurisy,  or  dysentery.  Again,  death  takes  place  from  extreme  exhaus- 
tion (variola  typhosa  sen  adynamica  of  old  authors).  In  favorable 
cases  the  temperature  gradually  falls  to  the  normal,  or  it  becomes  more 
irregular,  when  it  is  of  evil  augury.  With  the  former  change  the  appe- 
tite returns  and  the  eyes  are  again  visible.  In  some  instances  it  is  found 
that  pustules  have  existed  on  the  conjunctiva;  more  rarely  the  cornea 
is  likewise  involved,  permanently  impairing  or  destroying  the  useful- 
ness of  the  eye.  Total  blindness  of  both  eyes  seems  to  have  been  far 
from  uncommon  in  former  times.  Again,  and  more  frequently,  the 
eyes  are  found  to  be  uninjured.  The  tongue  clears,  and  from  the 
fifteenth  to  the  eighteenth  day  the  crusts  drop  off,  leaving  reddish  or 
purplish  spots,  which  vary  in  color  according  to  the  condition  of  the 
surrounding  atmosphere,  changing  from  blue  to  red.  Soon  this  is  re- 
placed by  a  dark-brownish  pigmentation,  and  the  sites  of  former  lesions 
become  depressed,  forming  deep  pits  or  extensive  areas  of  scar-tissue 
caused  by  the  destruction  of  the  superficial  layers  of  the  skin.  (See 
Plates  XV  and  XVII.)  As  the  crusts  separate  from  the  skin,  the  hair 
falls  out  in  tufts,  either  with  the  hardened  concretions  or  upon  the 
slightest  traction.  Whether  the  alopecia  will  be  permanent  or  not 
depends  upon  the  depth  to  which  the  destructive  inflammation  has  ex- 
tended. Usually  the  papilla?  are  not  wholly  destroyed,  in  which  case 
the  hair  returns.  It  is  not  infrequently  changed  in  texture,  presenting 
an  appearance  of  irregular  growth;  at  other  times  it  comes  out  thick 
and  curly,  which  may  be  quite  unlike  its  previous  condition.  The  same 
holds  true  of  the  beard.  The  nails  seldom  become  implicated,  except 
to  a  slight  degree,  and  then  not  sufficiently  to  interfere  with  their 
growth. 

In  those  who  survive  recovery  takes  place  slowly,  and  the  disease 
is  often  complicated  by  secondary  infection  of  pus-cocci  as  in  the 
discrete  form.  In  the  confluent  form,  however,  this  is  more  general, 
and  the  involvement  of  the  internal  organs,  which  is  often  of  a  serious 
character,  may  lead  to  permanent  impairment  of  health  or  terminate 
fatally. 


PLATE  XIII. 


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PLATE  XIV. 


PLATE  XIV. 


Variola,    Same  as   Preceding,    showing   Feet,    which    Present    Later   Stage  of  Eruption. 


PLATE  XV. 


PLATE  XV. 


Variola:     Confluent   on    Face,    Semiconfluent    and    Discrete   on    Other    Parts   of  the    Body. 
Mucous   Membranes  of   Mouth   and   Throat   Covered    with   Well-Formed    Pustules. 


PLATE  XVI. 


VARIOLA.  47 

THE  SEMICONFLUENT  OR  COHERENT  FORM. 

We  must  not  lose  sight  of  the  fact  that  the  terms  discrete  and  con- 
fluent are  purely  arbitrary,  and  that  the  clinical  forms  they  represent 
often  merge  imperceptibly  into  each  other.  This  is,  to  a  less  extent, 
true  of  other  clinical  forms.  As  its  name  implies,  semiconfluent  small- 
pox is  a  recognized  connecting-link  between  the  two  extremes  of  variola 
vera.  In  this  country  semiconfluent  small-pox  is  one  of  the  most  fre- 
quent forms,  and  in  some  epidemics  it  represents  the  severest  variety 
the  disease  assumes.  In  the  Cleveland  epidemic  of  1898-1901  it  was  ex- 
tremely common,  and  occurred  in  those  who  had  either  never  been  vac- 
cinated or  in  those  in  whom  the  vaccination  took  place  in  infancy, 
twenty  or  more  years  previously.  (Plates  XV  and  XVII.)  The  face  is 
the  part  most  frequently  as  well  as  the  most  severely  involved;  next 
come  the  hands  and  forearms.  Apparently,  surfaces  exposed  to  the 
light  suffer  more  severely  than  do  those  which  are  protected  by  the 
clothing,  although  the  increased  vascularity  of  the  part  is  probably  a 
greater  determining  factor.  The  disease,  while  severe,  is  not  so  fatal 
as  the  confluent  or  the  corymbose  form.  In  fact,  recovery  takes  place 
without  serious  complications  in  the  majority  of  cases  about  the  fourth 
week. 

THE  CORYMBOSE  FORM. 
(Variola  corymbosa,  from  xfywwSoj,  a  cluster  of  fruit.) 

This  is  a  rare  form,  in  which  the  pocks  group  themselves  into 
variously-sized  clusters;  hence  the  name,  which  was  used  by  Sauvages,79 
who  refers  to  Helvetins  as  having  employed  it  to  indicate  a  species  of 
malignant  aggregation  of  pustules  most  commonly  met  with  on  the 
face,  while  Marson  (loc.  cit.,  p.  229)  of  the  London  Small-pox  Hospital, 
used  it  to  denote  symmetrical  groups  distributed  over  various  parts  of 
the  body. 

A  case  of  corymbose  small-pox  observed  at  the  Cleveland  Small- 
pox Hospital  during  the  past  year,  from  which  the  accompanying  pho- 
tograph was  taken,  presented  palm-sized  clusters,  which,  when  fully  de- 
veloped, assumed  the  appearance  of  large,  flat  blisters.  (Plate  XVIII.) 
They  were  distributed  symmetrically  on  the  forearms  and  legs.  On 
other  parts  of  the  body  the  lesions,  while  thickly  distributed,  were 
discrete.  The  mucous  membranes  were  likewise  involved  as  in  ordi- 


'  Sauvages  (F.  B.):  "Nosologia  Methodica"  (Lipsae,  1791),  ii,  p.  265. 


48  THE    ACUTE    EXANTHEMATA. 

nary  small-pox.  The  case,  although  severe  and  somewhat  prolonged, 
pursued  a  normal  course,  and  finally  recovered.  During  convalescence 
numerous  boils  and  deep  abscesses  appeared  under  the  skin  on  various 
parts  of  the  body.  Sometimes  the  clusters  are  smaller,  being  silver- 
dollar  sized,  when  they  are  usually  more  numerous.  In  all  cases  there 
is  a  tendency  to  a  symmetrical  distribution.  According  to  J.  W. 
Moore,  they  appear  most  frequently  in  the  armpits,  groins,  and  the 
popliteal  space.  Most  observers  record  a  high  death-rate  in  this  form. 
In  the  London  Small-pox  Hospital  a  mortality  of  40  per  cent,  has  been 
recorded.80  Its  fatality  is  far  greater  than  one  would  expect  from  the 
extent  of  the  eruption.  The  surface  involved  is  generally  less  than  in 
the  semiconfluent  variety,  while  in  fatality  it  ranks  with  malignant 
small-pox.  If  the  patient  survive  the  active  course  of  the  disease  there 
is  a  marked  tendency  to  complications  during  the  stage  of  convales- 
cence, which  is  always  tedious  and  prolonged. 

VARIOLA  H^MOERHAGICA. 

(Heemorrhagic    small-pox,    black    small-pox,    variola    nigra, 
variola  maligna,  etc.) 

Formerly  black  small-pox  was  far  more  common  than  at  present; 
in  fact,  we  have  reason  to  believe  that  it  was  the  usual  form  in  numer- 
ous epidemics  covering  a  very  long  period.  In  more  recent  times,  from 
the  protective  influence  of  vaccination,  and  probably  from  improved 
sanitary  conditions  alluded  to  elsewhere,  it  is  less  frequently  encoun- 
tered. 

THE  PURPURIC  FORM. 
(Variola  purpurica,  purpura  variolosa,  schwarzen  tod,  etc.) 

While  it  may  be  impossible  to  foretell  the  appearance  of  hsemor- 
rhagic  variola  in  the  majority  of  cases,  yet  in  the  purpuric  variety  the 
uncertainty  is  of  short  duration;  besides  there  are  certain  conditions 
which  are  known  to  predispose  to  this  form.  Thus,  a  hsemorrhagic 
diathesis  or  the  previous  incidence  of  purpura  may  be  considered  as 
strongly  predisposing  to  this  variety.  On  the  other  hand,  it  appears 
in  young  and  robust  people  who  have  never  had  any  previous  illness 
to  indicate  the  haemorrhagic  tendency.  Next  to  the  natural  "bleeders" 


80  Marson  (loc.  cit.). 


PLATE  XVII. 


PLATE  XVII. 


Same   as   in    Plate   XV  After   Recovery,    showing   Permanent   Scarification   of  the   Skin. 


PLATE  XVIII. 


o 


VARIOLA.  49 

purpuric  variola  occurs  most  frequently  in  drunkards,  pregnant  or 
lying-in  women,  and  those  convalescing  from  disease  or  otherwise  de- 
bilitated. 

In  the  Dublin  epidemics  of  1871,  1878,  and  1894-95,  J.  W.  Moore 
observed  haemorrhagic  small-pox  most  frequently  in  young  and  robust 
subjects,  in  muscular  men,  and  women  who  were  either  pregnant  or 
had  been  recently  delivered.  This  variety  is  characterized  by  the  early 
appearance  and  violence  of  the  haemorrhagic  symptoms  and  by  the 
rapid  fatality  of  the  disease.  The  first  indications  of  its  serious  nature 
are  met  with  during  the  initial  stage.  The  temperature,  as  a  rule,  rises 
more  gradually  than  is  usual  in  variola  vera,  rarely  exceeding  103°  or 
104°  F.  (40°  C.),  and  not  infrequently  102°  F.  (38.8°  C.)  is  the  highest 
point  reached.  Unlike  the  forms  previously  considered,  the  pulse-rate 
does  not  correspond  to  the  elevation  of  temperature,  being  more  rapid 
and  compressible,  and  not  infrequently  attaining  a  rapidity  of  145  to 
160  beats  in  the  minute.  On  the  other  hand,  the  symptoms  may  re- 
semble those  of  variola  vera,  previously  given.  There  is  always,  how- 
ever, intense  aching  in  the  back,  with  great  prostration  and  pain  in  the 
prsecordial  region,  accompanied  by  vomiting,  which  is  prolonged,  the 
ejecta  consisting  of  dark-colored  material  mixed  with  bile.  In  this 
form  the  prodromal  eruption  is  of  frequent  occurrence,  and  shows  a 
haemorrhagic  character  soon  after  its  appearance.  Thus,  instead  of  a 
diffuse  erythema  which  is  more  common  in  the  mild  forms  of  variola, 
the  prodromal  rash  now  appears  in  the  form  of  small  maculae  of  pin- 
head  size  and  deep-red  color,  which  do  not  wholly  disappear  on  pressure. 
Upon  close  inspection  the  puncta  are  found  to  consist  of  small  haemor- 
rhages into  the  lower  strata  of  the  epidermis.  These  enlarge  to  millet- 
seed-sized  papules  of  a  dark-bluish  color,  and  finally  become  thickly 
and  widely  distributed  over  the  body. 

Again,  according  to  Curschmann,  large  extravasations  of  petechia?, 
situated  upon  an  erythematous  base,  may  sometimes  be  observed.  He 
further  remarks  that  they  are  usually  small  and  discrete  on  the  ex- 
tremities and  more  confluent  on  the  breast  and  abdomen,  where 
they  sometimes  attain  the  size  of  a  half-dollar.  They  may,  how- 
ever, be  irregularly  distributed.  They  seldom  occur  on  the  face, 
Taut  the  skin  is  red  and  puffy,  and  the  conjunctiva?  are  not  infre- 
quently blood-shot,  and  dark  rings  may  be  observed  around  the 
eyes,  due  to  haemorrhage  into  the  loose  cellular  tissue  of  the  parts. 
This  symptom  is  especially  striking  and  forebodes  a  rapidly  fatal  ter- 
mination. The  mucous  surfaces  share  in  the  haemorrhagic  tendency, 


50  THE   ACUTE    EXANTHEMATA. 

and  copious  bleeding  from  the  nose  is  usually  an  alarming  symptom. 
The  mouth  is  affected  in  like  manner,  although  to  a  less  degree.  The 
gums  are  spongy  and  bleed  easily.  The  tongue  is  large  and  thickly 
coated,  presenting  a  light-yellowish  or  parboiled  appearance.  A  pseu- 
dodiphtheritic  membrane  is  sometimes  thrown  out  on  the  pharynx, 
which  readily  decomposes,  giving  rise  to  an  intensely  f  cetid  odor.  This, 
with  the  bloody  expectoration  and  frequent  vomiting  of  blood,  accom- 
panied by  dark  evacuations  from  the  bowels,  shows  the  general  and 
serious  character  of  the  disease.  The  urine  is  scanty,  turbid,  and  of  an 
offensive  odor.  Albumin  is  usually  detected  early  in  the  disease.  In 
women  menstruation  is  established  and  abortion  often  occurs,  followed 
by  violent  haemorrhage,  which  usually  continues  until  death.  In  all 
cases  there  is  a  rapid,  fluttering  pulse,  indicating  the  low  and  serious 
character  of  the  disease.  Death  usually  takes  place  at  or  before  this 
time.  If  the  patient  survive  the  initial  stage,  there  takes  place  a  slow 
retrogression  of  the  initial  rash,  and  papules,  or  ill-formed  pustules, 
appear  on  the  face,  indicating  the  advent  of  the  eruptive  stage.  They 
soon,  however,  take  on  the  purpuric  character.  Seldom  does  the  dis- 
ease go  on  to  full  maturity.  Unlike  fatal  cases  of  confluent  small-pox, 
the  mind,  as  observed  by  J.  W.  Moore,  remains  remarkably  clear  until 
within  a  few  hours  before  death.  Curschmann  remarks  that  few  are 
fortunate  enough  to  fall  speedily  into  delirium  or  coma.  Ziilzer81  has 
pointed  out  that  a  general  hyperaesthesia  or  anesthesia  of  the  skin,  with 
paralysis  of  the  extremities,  sometimes  takes  place  as  a  precursor  of 
death.  The  course  of  purpuric  variola  is  extremely  rapid,  and  death 
usually  relieves  the  horrible  condition  from  the  second  to  the  fifth  day 
of  the  disease.  It  is  exceptional  for  a  patient  to  survive  the  sixth  day. 
Should  this  occur,  however,  the  maturation  and  desiccation  of  the  le- 
sions go  on  much  as  in  other  forms,  excepting  that  recovery,  which 
is  indeed  seldom  observed,  is  very  protracted,  and  followed  by  anaemia 
.and  great  prostration  for  an  indefinite  period. 

THE  IL^MORRHAGIC  FORM  (Variola  Hamorrhagica  Pustulosd). 

Neither  the  previous  condition  of  the  patient  nor  the  initial  symp- 
toms of  the  disease  furnish  any  clue  to  the  subsequent  appearance  of 
this  variety.  As  a  rule,  the  initial  stage  is  ushered  in  with  great  severity 
and  a  rapid  rise  of  temperature.  The  symptoms,  however,  do  not  differ 


81  Ziilzer:    "Beitrage   zur    Pathologie    und    Therapie    der   Variola,"    Berliner    klin. 
Woch.,  1872,  No.  51. 


VARIOLA.  51 

from  those  observed  in  the  confluent  form  of  small-pox.82  As  in  the 
purpuric  form,  the  initial  or  prodromal  rash  is  of  frequent  occurrence. 
It  is,  however,  made  up  of  a  deep-colored  erythema,  with  dilatation  of 
the  superficial  cutaneous  capillaries  rather  than  of  punctate  extravasa- 
tions of  blood.  Accordingly,  it  disappears  on  pressure,  and  is  more 
evanescent  than  in  the  preceding  variety.  It  usually  fades  away  during 
the  second  or  third  day,  leaving  a  faint  brownish,  desquamative  sur- 
face. The  true  eruption  usually  appears  on  the  second  day,  and  differs 
in  no  way  from  that  observed  in  variola  vera.  Sometimes  the  initial 
symptoms  do  not  subside  with  the  beginning  of  the  eruptive  stage,  in 
which  case  the  temperature  either  remains  the  same  or  continues  to  rise 
until  death  takes  place,  which  usually  rapidly  follows.  At  other  times 
there  is  a  gradual  subsidence,  with  great  prostration,  a  weak  fluttering 
pulse,  and  subnormal  temperature.  This  is  not  infrequently  observed 
in  the  aged,  and,  as  in  the  preceding  form,  is  always  a  serious  omen. 
With  extensive  hemorrhages  the  temperature  may  fall  to  81°  F. 
(27.2°  C.),  while  the  pulse-rate  is  increased  to  between  140  and  160 
(Curschmann). 

In  some  instances  it  has  also  been  observed  that  the  development 
of  the  pocks  takes  place  more  slowly  than  in  variola  vera,  and  not  infre- 
quently they  never  attain  their  full  development.  Finally  a  dark-bluish 
discoloration  is  observed  at  the  base  or  periphery  of  the  pocks,  which  is 
first  noticeable  on  the  feet  and  legs.  Although  extravasation  of  blood 
may  take  place  at  any  time,  it  is  most  frequently  seen  on  the  fifth  or 
sixth  day,  or  during  the  stage  of  maturation.  The  extravasation  is  not 
always  confined  to  the  pocks  themselves,  but  sometimes  appears  in  the 
form  of  variously-sized  ecchymoses  between  the  small-pox  lesions.  At 
other  times,  though  more  rarely,  distinct  lentil-sized  bluish  dots  are 
seen  scattered  generally  over  the  skin  between  the  small-pox  lesions, 
as  in  the  purpuric  form.  It  may  be  remarked  that  this  is  sometimes 
confined  to  the  lower  extremities,  where  the  disease  first  appears.  On 
the  mucous  membranes  dark,  livid  spots  are  nearly  always  present. 
This  is  more  marked  in  those  exposed  to  light  and  the  external  air. 
Sometimes  the  so-called  diphtheritic  membrane  also  appears  in  the 
pharynx  and  adjacent  parts,  which,  as  previously  described,  rapidly  de- 
composes. Sponginess  of  the  gums,  which  are  of  a  dark  hue,  especially 
at  the  margin,  as  seen  in  scurvy,  is  likewise  observed.  Haemorrhages 

82  Curschmann  relates  an  instance  in  which  a  patient  suffering  from  severe  epigas- 
tric pain,  with  vomiting  and  high  fever,  was  sent  to  the  hospital  with  apparent  diagnosis 
of  intussusception.  It  proved,  however,  to  be  the  initial  stage  of  haemorrhagic  variola, 
which  rapidly  proved  fatal  (loc.  cit.,  pp.  345  and  346). 


52  THE    ACUTE    EXANTHEMATA. 

from  the  nose,  lungs,  rectum,  kidneys,  and  uterus,  as  in  purpura  vari- 
olosa,  appear  later.  In  females  metrorrhagia  is  not  uncommon,  to- 
gether with  conjunctival  haemorrhages,  bloody  stools,  expectoration  of 
blood,  and  ha?matemesis  as  previously  described.  There  is  great  irregu- 
larity in  the  appearance  of  these  symptoms;  many  may  be  absent,  and 
different  cases  present  different  degrees  of  severity.  The  course  of  this 
variety  is  more  protracted  than  in  purpura  variolosa,  but  almost  always 
quite  as  fatal.  Recovery  is  extremely  rare.  Usually  such  cases  have 
but  few  pustules,  or  the  haemorrhagic  tendency  develops  late  in  their 
Course.  The  absence  of  haemorrhage  in  the  internal  organs  lessens 
materially  the  severity  and  consequent  fatality  of  the  disease.  Accord- 
ing to  Curschmann,  this  form  more  frequently  occurs  in  older  persons, 
after  the  prime  of  life,  in  those  who  are  debilitated,  and  in  convales- 
cents. Pregnant  women  are,  according  to  this  observer,  particularly 
predisposed  to  this  form. 

SECONDARY  H.^EMORRHAGIC,  OR  EXUDATIVE,  FORM  (Variola 
cum  Hcemorrhagia  Secundaria). 

This  form  is  quite  distinct  from  the  two  preceding  varieties.  It 
may  be  regarded  as  a  purely  mechanical  complication  which  is  usually 
met  with  in  cases  of  moderate  severity,  although  otherwise  following 
a  normal  course.  A  case  recently  under  observation  in  the  Small-pox 
Hospital  presented  a  mild  form  of  confluent  small-pox.  During  the 
early  stage  of  maturation — the  patient  not  being  confined  strictly  to 
bed — it  was  noticed  that  lesions  on  the  feet  began  to  assume  a  dark- 
bluish  color.  This  gradually  became  more  marked,  and  finally  com- 
pletely changed  the  color  of  the  pustules.  The  process  extended  upward 
to  the  knees.  No  other  parts  of  the  body  were  affected.  In  time  nearly 
all  the  pustules  of  this  region  became  entirely  replaced  by  a  dark-bluish 
fluid.  The  patient  made  a  good  recovery,  although  the  large  excoria- 
tions on  the  feet  retarded  convalescence,  and  necessitated  his  remaining 
in  a  recumbent  position  for  man}-  weeks.  It  is  usually  observed  in 
people  who,  either  in  delirium  or  otherwise,  assume  an  erect  position 
when  in  a  weakened  state,  the  extravasation  being  the  result  of  debility 
rather  than  of  any  predisposition  or  abnormal  tendency  to  haemorrhage. 
Curschmann  (ioc.  cit.,  p.  370)  speaks  of  it  as  not  uncommon  in  delirious 
patients  who  leave  their  beds  and  run  about,  and  relates  the  case  of  a 
girl,  twenty-one  years  of  age,  who  entered  the  hospital  during  the 
suppurative  stage  of  a  mild  attack  of  discrete  variola,  with  the  ominous 
diagnosis  of  "Variola  nigra."  Upon  investigation  it  was  found  that 


VARIOLA.  o3 

the  disease  had  been  running  a  normal  course  until  under  the  influence 
of  a  slight  delirium  potatorum,  being  poorly  attended,  she  left  her  bed 
and  rambled  about  the  room  during  the  entire  night  and  a  greater  part. 
of  the  following  day,  when  it  was  observed  that  nearly  all  the  pocks  on 
the  feet  and  legs  up  to  the  thighs  were  filled  with  blood. 

VARIOLA  MODIFICATA. 

(Varioloid,  modified  and  anomalous  small-pox,  variola  miti- 
gata,  variola;  anomalw.) 

Small-pox,  as  previously  shown,  does  not  always  follow  a  uniform 
course,  nor  is  it  of  equal  severity  in  all  persons  attacked.  In  severity 
it  likewise  differs  in  different  epidemics.  Undoubtedly  individual 
peculiarities  have  much  to  do  in  determining  not  only  the  severity  of 
the  disease,  but  also  its  duration  and  clinical  features.  We  occasion- 
ally meet  with  persons  who  seem  to  possess  a  natural  immunity  to  the 
contagion,83  others  in  whom  the  disease  assumes  a  mild  form,  even 
when  not  under  the  protective  influence  of  vaccination  or  a  previous 
attack  of  variola.  Since  the  introduction  of  vaccination,  however,  these 
modified  forms  of  the  disease  have  become  far  more  common.  In  fact, 
at  the  present  day,  with  general  vaccination  in  vogue,  varioloid  is  not 
only  the  most  common,  but  of  the  greatest  importance  to  the  physician, 
on  account  of  its  harmless  appearance  and  the  difficulty  of  maintaining 
strict  quarantine  regulations.  For  we  must  not  lose  sight  of  the  fact 
that  all  forms  of  small-pox  are  essentially  the  same,  and  the  source  of 
contagion,  whether  it  be  from  a  mild  or  a  malignant  case,  affords  no 
criterion  as  to  the  form  the  disease  may  assume  in  those  exposed.  Those 
who  cherish  the  thought  that  the  disease  itself  has  undergone  modifica- 
tion, must  at  intervals  find  this  fond  hope  dispelled  by  an  epidemic  of 
old-time  severity.  This  was  especially  the  case  in  Montreal  in  1885, 
when  the  general  prejudice  and  neglect  of  vaccination  led  to  one  of  the 
severest  "epidemics  of  recent  times.  Some  epidemics,  it  is  true,  present 
only  the  mild  or  modified  forms  of  the  disease,  or  at  least  symptoms  so 
mild  as  to  render  the  diagnosis  of  many  cases  confusing  to  those  who 
are  not  thoroughly  familiar  with  it.  In  every  epidemic  there  are,  how- 
ever, certain  individuals  who  develop  the  severer  forms  of  variola,  show- 
ing that  the  poison  is  the  same  in  each.  Varioloid  is,  therefore,  a  mild 
form  of  small-pox  usually  occurring  in  those  who  have  been  vaccinated 
or  have  previously  had  the  disease.  It  is  a  fact  commonly  observed  that 

83  Morgagni,  Boerhaave,  and  Diemerbrock,  it  is  said,  possessed  this  peculiarity. 


54  THE   ACUTE    EXANTHEMATA. 

vaccination  protects  against  the  development  of  the  variola  poison  for 
a  certain,  though  variable,  period.  Gradually  the  time  arrives  when  the 
system  loses  the  complete  protective  influence  of  vaccinia,  and,  if  ex- 
posure take  place,  a  mild  form  of  variola  develops,  which  is  called  vario- 
loid.84  Likewise  one  attack  of  variola  usually  confers  a  life-long 
immunity  to  the  disease.85  After  the  lapse  of  many  years,  however, 
occasional  exceptions  occur.  Thus,  it  is  commonly  reported  that  Louis 
XV  of  France  suffered  from  small-pox  at  the  age  of  fourteen,  and  con- 
tracted it  again  when  sixty-four  years  old,  from  which  he  died.  This 
instance  is  frequently  cited,  because  it  not  alone  presents  an  exception 
to  the  rule  of  complete  life-long  immunity,  but  apparently  to  the  mild 
nature  of  a  second  attack  as  well.  Hebra,  it  may  be  remarked,  held 
strongly  to  the  opposite  opinion,  for  he  says:  "I  have  repeatedly  had 
occasion  to  observe  that  persons  who  had  before  been  attacked  by  vari- 
ola, and  who  presented  the  most  marked  cicatrices,  have  died  of  this 
complaint  when  seized  with  it  for  the  second  time  in  a  severe  form" 
(loc.  cit.,  p.  263).  Hebra,  it  must  be  remembered,  made  no  distinction 
between  varicella  and  variola.  Trousseau  likewise  relates  the  case  of  a 
medical  student  who,  although  he  had  previously  suffered  from  two 
attacks  of  small-pox  from  which  he  "was  badly  pitted,  contracted  it  a 
third  time  in  a  moderately  severe  form.  Mason  Good,86  on  the  con- 
trary, observed  only  the  crystalline  form  of  horn-pox  in  second  attacks 
of  variola.  I  believe  the  weight  of  authority,  and  especially  the  testi- 
mony of  those  who  have  had  most  to  do  with  variola  in  this  country, 
confirms  the  statement  that  small-pox,  when  occurring  a  second  time 
in  the  same  individual,  is  usually  of  a  mild  or  modified  character,  and 
when  not  complicated  by  old  age  or  other  debilitating  conditions  is  sel- 
dom fatal. 

The  disease  presents  greater  variability  both  in  the  duration  of  its 
stages  and  in  the  appearance  of  the  eruption  than  is  seen  in  variola 
vera.  The  fatality  of  the  disease  is  low,  and,  as  a  rule,  it  is  of  shorter 
duration  than  in  the  forms  previously  described.  The  premonitory 
symptoms  may  be  severe,  and  the  temperature  not  infrequently  rises  to 


84  Varioloid  was  formerly  thought  by  some  to  be  a  distinct  affection  resembling 
variola,  while,  according  to  Rayer,  the  term  was  first  used  by  Thomson,  of  Edinburgh, 
In  1820  to  include  varicella  and  all  mild  affections  which  he  supposed  to  be  modifications 
of  the  variola  poison.    Rayer  (P.):    "Traite  Maladies  de  la  Peau"   (Paris,  1835),  tome  i, 
p.  577. 

85  According  to  Marson  (loc.  cit.,  p.  243),  during  the  one  hundred  and  nineteen  years 
since  the  founding  of  the  London   Small-pox  Hospital  not  a   single   instance  has   been 
recorded  of  a  patient  being  admitted  with  small-pox  a  second  time. 

88  Good  (Mason):  "Study  of  Medicine"  (New  York,  1827),  vol.  iii,  p.  78. 


VARIOLA. 


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56  THE   ACUTE    EXANTHEMATA. 

104°  F.  (40°  C.),  or  even  higher.  As  a  rule,  however,  the  intensity  of 
the  disease  is  seen  to  be  modified  even  in  the  initial  stage,  and  the  usual 
symptoms  are  less  constant.  Sometimes  they  consist  only  of  frontal 
headache,  at  other  times  of  nausea  and  vomiting,  although  pain  or 
aching  in  the  back  is  seldom  wholly  absent.  The  initial  stage  is  of 
longer  duration  than  in  variola  vera,  the  eruption  appearing  on  the 
fourth  day,  although  it  may  be  delayed  until  the  morning  of  the  fifth 
day.  The  eruption  may  sometimes  be  seen  as  early  as  the  second,  or 
in  very  rare  instances  on  the  first  day  of  the  disease. 

With  the  older  writers,  Trousseau  (op.  cit.,  pp.  86  and  87)  claimed 
that  the  initial  roseola  was  seen  only  in  varioloid.  While,  as  previously 
stated,  great  variability  is  shown  in  different  cases,  and  in  different  epi- 
demics, yet  there  can  be  no  question  that  the  erythematous  initial 
eruption  is  more  frequently  met  with  and  more  widely  distributed  in 
the  mild  than  in  the  severe  forms  of  the  disease.  Its  presence,  there- 
fore, is  of  prognostic  significance.  It  is  well  to  bear  in  mind  in  this 
connection  that  the  petechial  rash  which  so  frequently  precedes  the 
ha?morrhagic  and  fatal  form  of  variola  is  never  encountered  in  vario- 
loid. Curschmann,  whose  wide  experience  enables  him  to  speak  with 
authority  on  this  subject,  does  not  remember  having  seen  variola  vera 
follow  a  well-marked  simple  initial  erythema  (loc.  cit.,  p.  377).  With 
Hebra  and  Trousseau,  he  also  believes  that  the  subsequent  development 
of  the  pocks  is  less  severe  according  as  the  initial  eruption  is  more 
extensive. 

The  disease  may  terminate  with  the  initial  stage  (variola  sine 
varivlis)  and  the  patient  recover  within  from  three  to  five  or  six  days. 
These  abortive  attacks  not  infrequently  follow  well-marked  and  even 
severe  initial  symptoms.  Such  cases  have  been  recorded  by  Hilton 
Fagge,87  Landucci,88  Simon,  Marson,  and  Curschmann.  The  last- 
named  especially  offers  evidence  which  seems  convincing.  Thus,  a 
woman  during  an  epidemic  of  variola  was  suddenly  seized  with  shiver- 
ing, fever,  and  headache.  This  was  accompanied  by  a  severe  pain  in 
the  back,  which  rendered  the  diagnosis  of  small-pox  well-nigh  certain. 
After  the  initial  stage,  on  the  fourth  day,  defervescence  took  place, 
although  no  rash  could  be  detected,,  and  on  the  tenth  day  she  was  pro- 
nounced well.  Soon  after  this  she  gave  birth  to  an  infant  which  was 
covered  with  an  early  eruption  of  variola,  which  went  on  to  suppuration 
and  proved  fatal. 

87  Quoted  by  J.  W.  Moore  (loc.  cit.,  p.  423). 

88  Landucci,  cited  in  London  Lancet,  1871,  i,  p.  56. 


•  VARIOLA.  57 

Marson89  likewise  reports  the  case  of  a  lady  who  came  in  contact 
with  a  person  affected  with  small-pox.  Twelve  days  later  she  was  seized 
with  a  severe  illness,  accompanied  by  high  fever  and  delirium.  This 
subsided  on  or  about  the  fourth  day,  and  she  recovered  without  further 
symptoms  of  variola.  Twelve  days  after  this,  however,  a  sister  who 
had  not  been  out  of  the  house  for  some  months  was  attacked  with  vari- 
ola which  assumed  a  confluent  form.  The  present  writer  has  likewise 
observed  such  cases  during  epidemics  of  small-pox. 

At  other  times  the  eruptive  stage  appears,  and  the  pocks  during 
the  first  day  become  acuminated  and  progress  no  further  (variola  cornea, 
or  Tiorn^pox],  or  are  surrounded  by  a  small  vesicle  which  does  not  de- 
velop into  a  full-sized  lesion,  but  soon  begins  to  shrivel  without  signs 
of  suppuration,  forming  a  reddish  papillary,  or  wart-like  eruption 
which  is  called  wart-pox,  or  variola  verrucosa.  This  form  is  best 
marked  on  the  face,  where  the  lesions  are  often  quite  numerous,  while 
but  few  are  usually  seen  on  other  parts.  This  variety  is  of  short  dura- 
tion and  its  whole  course  does  not  exceed  ten  days,  and  is  frequently 
less.  When  the  eruption  ends  with  the  full  development  of  vesicles, 
it  is  called  crystalline  small-pox,  or  variola  crystallina.  The  name 
variola  miliaris  is  applied  to  a  more  common  anomaly  in  which  there 
appear  either  on  the  initial  eruption,  or  later,  between  the  more  mature 
pocks,  small  millet-seed-sized  vesicles  which  take  on  a  slightly  yellowish 
tint,  and  desiccate  without  developing  into  full-grown  lesions.  They 
are  liable  to  render  the  nature  of  the  eruption  obscure.  Sometimes 
there  is  a  retrogression  of  the  pustules,  in  which  case  their  contents 
become  absorbed,  leaving  empty  shells  containing  only  air,  to  which 
the  term  variola  siliquosa  is  applied.  This  has  been  observed  likewise 
in  variola  vera,  when  it  is  of  more  serious  import.  Aside  from  these 
abortive  forms,  varioloid  more  frequently  goes  through  the  various 
stages  of  development  and  desiccation. 

On  or  about  the  fourth  day  the  eruptive  stage  begins  with  the 
appearance  of  reddish  dots,  as  in  variola  vera.  These  are  likewise  most 
commonly  observed  first  on  the  face  and  subsequently  on  the  trunk  and 
extremities.  There  are  numerous  exceptions,  far  more  than  in  variola 
vera,  and  this  order  may  be  reversed.  On  the  face,  however,  the  erup- 
tion is  always  more  abundant  and  is  usually  grouped  or  in  clusters, 
especially  about  the  nose  and  mouth.  With  the  appearance  of  the  erup- 
tion the  temperature  rapidly  subsides  and  within  a  day  or  two  returns 


89  Marson,  quoted  by  J.  W.  Moore  (loc.  cit.,  p.  423). 


58  THE    ACUTE    EXANTHEMATA. 

to  the  normal.  Other  initial  symptoms  likewise  disappear,  and  often 
the  patient  can  with  difficulty  be  restrained  from  going  about.  At  the 
end  of  the  first  day,  or  more  commonly  during  the  second,  small  vesi- 
cles appear  on  the  summits  of  the  conical  papules.  At  this  time  I  have 
repeatedly  observed  lentil-sized  pustules  on  the  trunk,  which  do  not 
present  the  appearance  of  well  formed  pocks,  but  resemble  small  blis- 
ters containing  a  sero-purulent  fluid,  situated  on  the  normal  skin. 
(Plates  XIX  and  XX.)  They  present  neither  induration  nor  sur- 
rounding areola,  and  when  punctured  they  completely  subside  and  no 
reaccumulation  takes  place.  This  has  led  some  to  look  upon  the  affec- 
tion as  varicella  rather  than  varioloid. 

Case  I. — A  girl,  aged  twenty-three,  complained  of  slight  malaise, 
accompanied  with  some  distress  in  the  stomach  and  followed  by  fever, 
which  gradually  attained  the  height  of  104°  F.  during  a  period  of  three 
or  four  days.  Following  this  an  eruption  appeared,  although  the  med- 
ical attendant,  who  had  discontinued  his  visits  upon  the  subsidence  of 
the  fever,  was  not  notified  until  about  three  days  after  the  eruption 
was  first  observed  by  the  patient's  mother.  There  being  some  doubt 
as  to  the  nature  of  the  affection,  I  was  called  in  consultation,  when  an 
opportunity  was  given  to  study  the  eruption.  Upon  examination  the 
patient  was  found  to  be  in  a  fairly  comfortable  condition,  her  appetite 
was  unimpaired,  and  no  pains  or  aches  were  complained  of.  On  the 
face,  grouped  about  the  nose  and  mouth,  were  about  a  dozen  reddish 
papules,  the  size  of  small  peas,  some  of  which  presented  an  opalescent, 
glazed  top.  On  the  trunk,  especially  between  the  shoulders,  were  a  few 
lesions,  pustular  in  character,  presenting  the  appearance  of  thin-walled 
blisters,  which  varied  in  size  from  a  pin-head  to  that  of  a  small  pea. 
Many  had  ruptured,  leaving  a  flattened,  excoriated  base  covered  with 
epidermic  debris  and  crusts.  No  induration  was  present.  There  were 
also  a  few  small  papules  and  slightly  opalescent  vesicles.  On  the  arms 
and  legs  the  lesions  were  also  pustular,  but  indurated  at  the  base,  and 
could  not  be  completely  obliterated  by  puncturing.  On  the  palms  of 
the  hands  and  the  soles  of  the  feet  there  were  likewise  one  or  two  deep- 
seated  lesions.  The  pharynx  was  slightly  congested,  otherwise  unaf- 
fected. There  was  marked  debility,  considering  the  number  of  lesions, 
and  when  requested  to  stand  the  patient  could  do  so  with  difficulty, 
complaining  of  faintness.  On  the  face,  however,  the  lesions  were  deeply 
seated,  becoming  vesicular  and  going  through  the  various  stages  in  a 
regular  way,  although  more  rapidly  than  in  variola  vera.  The  special 
features  were:  The  variability  in  the  character  of  the  lesions  and  the 


PLATE  XIX. 


Varioloid,    p-eser.ting   Multiform    Lesions   resembling   a   Syphiloderma  or  Varicella. 


PLATE  XX. 


PLATE  XX. 


Varioloid,    Posterior  View   of  the   Preceding. 


VARIOLA.  ~><) 

irregular  order  in  which  they  developed.  She  was  sent  to  the  Small- 
pox Hospital,  and  in  about  eight  days  desiccation  was  well-nigh  com- 
plete. The  patient  had  never  been  vaccinated,  and  to  remove  a  linger- 
ing doubt  on  the  part  of  some  as  to  the  correctness  of  the  diagnosis 
instructions  were  given  to  the  resident  physician  that  she  be  guarded 
against  vaccination  while  in  the  hospital.  A  week  after  she  entered  the 
Small-pox  Hospital  another  member  of  the  family  was  seized  with 
variola  of  a  mild,  although  more  pronounced,  type. 

Case  II. — A  girl,  aged  twelve  years,  who  had  never  been  vac- 
cinated, complained  while  at  school  of  smarting  of  the  eyes  and  sensi- 
tiveness to  light.  The  following  day  the  family  observed  that  she  was 
feverish,  having  an  intensely  flushed  face,  and  complained  of  headache, 
which  was  followed  by  slight  nausea  and  vomiting,  the  latter  being 
attributed  to  cream  and  jelly  which. the  patient  had  eaten.  The  family 
physician  was  called  and  noted  a  slight  rise  of  temperature  and  a  papu- 
lar eruption  on  the  face.  At  this  time  the  patient  did  not  complain  of 
feeling  ill,  and  the  case  was  regarded  as  one  of  varicella.  Some  dis- 
agreement arose  as  to  the  correctness  of  the  diagnosis,  and  I  was  asked 
by  the  health  department  to  see  the  case.  I  did  so  with  the  family 
attendant,  and  although  unable  to  obtain  a  definite  history  of  the  pre- 
vious course  of  the  disease,  yet  did  not  hesitate  in  pronouncing  it 
variola.  At  this  time  the  lesions  were  numerous  on  the  face,  and  espe- 
cially well  marked  about  the  nose,  mouth,  and  forehead.  They  were 
pustular,  with  an  indurated,  reddish  base.  On  the  trunk  they  were  less 
numerous,  and  in  many  instances  had  ruptured,  leaving  lentil-sized  or 
larger  excoriated  areas.  There  were  also  small  pustules  varying  from 
a  pin-head  to  a  lentil  in  size,  together  with  a  few  small  papules.  The 
following  day  the  family  attendant  informed  me  that  the  lesions  had 
greatly  changed  and  a  second  examination  he  thought  would  compel 
me  to  render  a  different  opinion.  Accordingly,  twenty-four  hours  later, 
the  case  was  again  seen.  At  this  time  the  pustules  on  the  face  were 
rapidly  desiccating,  apparently  by  resorption  of  their  contents.  On  the 
hands  and  forearms  the  lesions  were  full  and  had  not  undergone  any 
perceptible  change,  excepting  that  they  had  increased  slightly  in  size. 
On  the  palms  of  the  hands  and  soles  of  the  feet  there  were  a  few  deep- 
seated  whitish  pustules.  On  the  trunk  there  was  a  variety  of  lesions, 
many  of  which  presented  small,  blister-like  pustules  situated  on  normal 
skin,  without  induration  or  inflammatory  margin.  When  puctured 
with  a  needle  these  anomalous  pocks  discharged  their  contents  and 
completely  flattened  to  the  level  of  the  skin.  Slight  friction  removed 


60  THE    ACUTE    EXANTHEMATA. 

the  flaccid  epidermis,  leaving  an  excoriated  area  quite  unlike  the  lesions 
of  variola  vera.  As  the  same  opinion  was  entertained  as  to  the  nature 
of  the  disease  she  was  sent  to  the  Small-pox  Hospital.  The  following 
day  at  the  same  hour  a  more  thorough  examination  than  had  previously 
heen  possible  was  made  in  the  hospital  ward.  At  this  time  the  lesions 
on  the  face  had  undergone  marked  desiccation,  and  many  of  the 
pustules  on  the  trunk  had  disappeared,  leaving  crusts  of  varying  thick- 
ness and  consistency.  A  few  remaining  lesions  presenting  the  non- 
indurated,  blister-like  character  previously  described  were  also  found 
on  the  arms  and  trunk.  These  subsided  upon  puncture  as  before. 
Other  lesions  which  were  more  fully  developed,  presenting  the  usual 
character  of  a  variola  pustule,  were  likewise  seen.  The  latter  did  not 
subside  on  puncture,  and  scraping  away  the  pustular  covering  left  an 
elevated,  ragged,  somewhat  indurated  base:  the  true  small-pox  lesion. 
The  hospital  physician  was  instructed  not  to  vaccinate  the  patient, 
although,  to  remove  all  uncertainty  in  his  mind,  and  without  authority, 
he  inoculated  the  patient  with  the  variola  virus.  A  brother,  two  years 
younger,  was  attacked  four  days  later,  and  presented  more  character- 
istic lesions.  When  first  seen  they  were  papular  and  the  next  day 
vesicular,  and  when  he  entered  the  hospital  they  were  well  formed 
pustules.  Both  cases  made  a  rapid  recovery,  the  disease  lasting  about 
ten  days.  The  variola  inoculation  in  the  first  patient,  it  may  be  re- 
marked, gave  a  negative  result. 

The  severity  of  the  constitutional  symptoms,  the  deep-seated  nature 
of  the  majority  of  the  lesions,  will  in  most  cases  enable  one  by  careful 
study  to  arrive  at  a  correct  diagnosis.  Secondary  fever  is  never  seen 
in  varioloid  excepting  from  some  concomitant  condition.  From  the 
fifth  to  the  seventh  day  desiccation  begins.  The  pustules  seldom  rupt- 
ure, but  the  contents  undergo  retrogressive  changes,  becoming  smaller 
and  finally  form  dark-brown  crusts,  which  in  a  few  days  are  cast  off, 
leaving  reddish,  slightly  pigmented  spots.  The  mucous  membranes  are 
likewise  sometimes  involved,  most  frequently  the  pharynx  and  palate. 
There  may  be  but  a  simple  erythema,  or  distinct  lesions  may  at  times  be 
discerned.  The  tongue  in  most  cases  is  thickly  coated,  although  it  does 
not  swell  as  in  variola  vera.  Eecovery  takes  place  in  the  majority  of 
cases  within  a  fortnight,  and  complications  and  sequelae  seldom  occur. 

THE  INOCULATED  FORM. 

When  a  susceptible  individual  is  inoculated  with  the  pus  of  small- 
pox, the  following  symptoms  take  place:  In  from  one  to  two  days  there 


VARIOLA. 


61 


62  THE    ACUTE    EXANTHEMATA. 

is  a  slight  redness  at  the  point  of  inoculation,  such  as  might  result  from 
a  simple  irritation.  During  the  following  three  or  four  days  cedema, 
with  the  formation  of  a  papule,  is  observed.  This  soon  develops  into 
a  pustule,  which  resembles  somewhat  that  of  variola.  On  the  sixth  day 
a  dull  pain  is  felt  in  the  axilla,  and  on  the  eighth  day  the  patient  feels 
ill  and  the  initial  somatic  symptoms  set  in.  In  many  respects  they  are 
similar  to  those  observed  in  the  initial  stage  of  the  other  forms  of 
variola,  excepting  that  they  are  almost  uniformly  of  a  milder  nature. 
The  fever  does  not  attain  the  height  previously  noted  in  other  forms, 
and  vomiting,  prostration,  and  delirium  are  usually  absent.  There 
is  usually  some  sickness,  which  is  referred  to  the  stomach,  with 
pain  in  the  back  and  frontal  headache.  The  various  stages  of  the 
disease  are  shorter  than  in  the  natural  form,  and  the  rash  appears 
on  the  third  day.  It  follows  in  regular  order  similar  to  that  ob- 
served in  the  discrete  form  of  variola  vera,  first  appearing  on  the  face 
and  head,  then  on  the  hands,  trunk,  and  extremities.  Its  invasion  is 
more  rapid,  and  not  infrequently  even  during  the  first  day  the  out- 
break may  be  complete.  Some  variability  also  exists  in  this  form,  for. 
while  the  majority  of  cases  follow  a  short  and  favorable  course,  others 
are  severe  and  some  confluent.  On  the  sixth  or  seventh  day  the  lesions 
are  usually  complete,  and  desiccation  takes  place  soon  afterward. 
There  is  usually  very  little  or  no  secondary  fever,  and  by  the  thirteenth 
or  fifteenth  day  the  crusts  are,  for  the  most  part,  cast  off,  and  recovery 
is  complete.  The  mildness  of  the  attack  was  early  recognized,  and  the 
custom  of  inoculating  with  the  virus  of  small-pox  was  adopted  at  a  very 
remote  period,  as  elsewhere  shown.  Even  in  modern  times  the  custom 
was  wide-spread,  and  many  now  living  can  recall  the  time  when  it  was 
universally  practiced  in  the  British  Isles  and  in  America.  From  the 
great  fatality  caused  by  the  more  extensive  diffusion  of  variolous  con- 
tagion among  those  who  were  not  inoculated,  as  well  as  from  the  fact 
that  inoculation  does  not  always  insure  a  mild  attack,  it  was  finally  dis- 
carded and  laws  were  enacted  against  its  practice.  The  introduction  of 
vaccination,  however,  has  entirely  superseded  it,  and  "sowing"  or  "buy- 
ing" the  small-pox  is  now  regarded  as  a  relic  of  semibarbaric  times. 

COMPLICATIONS  AND  SEQUELAE. 

In  addition  to  the  complications  which  modify  the  symptoms  of 
the  disease  already  described,  variola  frequently  gives  rise  to  conditions 
which  call  for  further  consideration. 

The  Skin. — One  of  the  most  constant  conditions  following  the 


VARIOLA.  G3 

various  forms  of  small-pox  is  the  deposition  of  pigment  in  the  areas 
of  skin  previously  involved  in  the  variola  process.  It  appears  in  the 
form  of  macula?  having  a  distinct  border,  and  varying  both  in  shape 
and  size  according  to  the  former  small-pox  lesion.  After  their  dis- 
appearance, whitish  cicatrices  are  seen,  due  to  the  destruction  of  the 
papillary  layer  of  the  derma.  It  was  formerly  the  custom  to  bind  the 
hands,  or  inclose  them  in  mittens,  to  prevent  injury  to  the  skin  from 
scratching.  This  is  now  known  to  depend  more  on  the  depth  of  the 
destructive  inflammatory  process  than  to  any  irritation  caused  by  the 
finger-nails,  although  the  introduction  of  extraneous  substances  may  be 
facilitated  and  the  inflammation  aggravated  by  vigorous  scratching. 
The  phlegmonous  abscesses  of  the  skin  and  subcutaneous  cellular  tissue 
may  persist  long  after  the  true  small-pox  lesions  have  disappeared.  J. 
W.  Moore  relates  an  instance  in  the  Dublin  Fever  Hospital,  in  which 
as  many  as  forty-two  abscesses  followed  a  case  of  confluent  small-pox, 
and  the  unfortunate  sufferer  was  confined  to  the  hospital  for  nine 
months  before  recovery  took  place. 

In  the  Cleveland  Small-pox  Hospital  we  have  not  infrequently 
seen  large  subcutaneous  abscesses,  more  protracted  and  withal  of  greater 
danger  to  life  than  the  attack  of  variola  which  preceded  them.  In  mild 
attacks,  especially  when  the  patient  has  been  allowed  to  walk  about, 
or  to  sit  with  his  feet  on  the  floor,  the  legs  have  most  frequently  been 
the  seat  of  these  coccogenous  sequela?.  When  the  disease  has  been 
more  severe,  as  in  confluent  variola,  various  other  parts  of  the  body 
show  an  equal  tendency  to  their  formation.  Thus,  the  arms,  scalp, 
neck,  and  trunk  may  be  involved,  or  occasionally  the  deeper  cellular 
tissues,  as  in  the  axilla?  or  about  the  rectum,  giving  rise  to  an  abscess 
which  may  occasion  an  ischio-rectal  fistula.  Codina  Castellvi90  has  ob- 
served a  psoas  abscess  in  a  convalescent  from  variola. 

Although  the  pus-organisms  may  cause  extensive  destruction  of 
various  parts,  yet  gangrene  is  seldom  observed,  excepting  occasionally 
in  the  scrotum  and  over  bony  prominences  subjected  to  constant  press- 
ure, bed-sores  forming  as  in  other  diseases.  Marson  has  observed  gan- 
grene of  the  genitals  as  of  frequent  occurrence  in  women  of  the  town 
afflicted  with  gonorrhoea.  Loss  of  hair  sometimes  takes  place,  which  is 
either  temporary  or  permanent  according  as  the  hair  papilla  is  or  is  not 
destroyed.  Obstinate  pustular  acne  and  sycosis  vulgaris  in  men  are 
among  the  most  common  sequela?  of  small-pox. 

"Codina  Castellvi:  An.  de  Obst.,  Ginecopat,  y  Pediat.  (Madrid,  1898),  xviii,  pp. 
193-201. 


64  THE    ACUTE    EXANTHEMATA. 

The  Eyes. — Although  the  eyes  suffer  less  commonly  than  from 
the  older  authors  we  are  led  to  believe  took  place  at  one  time,  yet  per- 
manent impairment  of  vision  is  far  from  infrequent,  and  the  impor- 
tance of  close  attention  to  the  eyes  during  an  attack  of  variola  cannot 
be  too  strongly  urged.  In  5000  cases  of  variola  Hebra  (loc.  cit.,  p.  254) 
found  the  eyes  involved  in  only  1  per  cent.,  and  in  none  did  it  lead  to 
impairment  of  sight.  While  this  is  regarded  by  most  authors  as  a 
unique  experience,  it  has  served  to  stimulate  original  research  and  closer 
observation  in  this  direction. 

Aside  from  catarrhal  or  simple  acute  conjunctivitis,  which  is  com- 
mon after  all  forms,  great  disfigurement  of  the  eyelids  is  sometimes  ob- 
served after  confluent  small-pox.  This  may  be  the  result  of  sloughing 
from  cedema  of  the  lids,  or  the  pocks  may  give  rise  to  cicatrices  which 
differ  in  no  way  from  those  observed  on  other  parts  of  the  face,  except- 
ing that  by  contracting  they  occasion  greater  deformity. 

Marson  (loc.  cit.,  p.  234),  in  reviewing  the  notes  of  15,000  cases  of 
small-pox,  found  only  26  instances  in  which  the  primary  small-pox 
pustule  had  been  formed  on  the  eye.  In  none  of  the  patients  thus 
affected  did  permanent  injury  to  the  eyes  occur.  The  conclusions  ar- 
rived at  by  this  observer  were:  That  the  ulceration  which  leads  to  de- 
struction of  the  eye  in  small-pox  begins  after  the  secondary  fever  has 
commenced,  varying  from  the  tenth  to  the  thirteenth  day,  most  com- 
monly the  twelfth.  It  appears  with  redness  and  slight  pain  in  the  part 
affected,  followed  shortly  by  an  ulcer  having  its  seat  invariably  at  the 
margin  of  the  cornea.  This  spreads,  its  rapidity  being  in  proportion 
to  the  secondary  fever  present.  The  different  layers  of  the  cornea  are 
destroyed  and  the  aqueous  humor  escapes.  If  the  opening  be  large  the 
iris  may  be  seen  protruding,  and  sometimes  the  crystalline  lens  is  de- 
tached and  flows  out  with  the  vitreous  humor.  The  process  in  severe 
cases  with  high  fever  takes  place  rapidly,  the  entire  cornea  being  swept 
away  in  forty-eight  hours;  and,  as  but  little  pain  is  felt,  the  destruc- 
tion of  sight  may  take  place  before  the  serious  nature  of  the  affection  is 
detected. 

According  to  Homer,91  of  Zurich,  who  studied  the  subject  ex- 
haustively during  the  epidemic  of  1871,  pustules  on  the  cornea  are 
extremely  rare.  The  most  frequent,  as  well  as  the  most  serious  mode 
of  attack,  according  to  this  observer,  is  an  infiltration  into  the  con- 
junctiva of  a  grayish-yellow  color,  which  takes  place  at  the  lower 


91  Horner,  quoted  by  J.  W.  Moore  (loc.  cit.,  p.  432). 


VARIOLA.  65 

margin  of  the  cornea  and  rarely,  if  ever,  extends  to  the  fornix  con- 
junctivae  or  far  along  the  inner  or  outer  margins  of  the  cornea.  It  is 
met  with  in  the  eruptive  stage,  and  clinically  is  identical  with  the  regu- 
lar small-pox  lesions.  Like  a  solitary  marginal  phlyctenula,  it  leads  to 
an  affection  of  the  cornea,  forming  either  a  marginal  ulcer  or  a  deep 
purulent  infiltration.  This,  in  turn,  eventuates  in  perforation,  staphy- 
loma,  purulent  iridochoroiditis,  and  panophthalmitis.  From  the  posi- 
tion of  the  eyeball  when  the  lids  are  closed,  as  is  usual  in  this  stage, 
Horner  believes  the  morbific  substance  gains  access  to  the  conjunctiva 
from  without.  I  have  encountered  this  ^complication  but  once. 

Keratitis  is  likewise  met  with  late  in  the  course  of  variola  or  as  a 
sequela.  Unlike  the  preceding,  this  is  not  associated  with  the  eruptive 
stage,  but  results  more  commonly  from  atrophy  due  to  impaired  nutri- 
tion. The  term  "atrophic  keratitis"  is  sometimes  applied  to  this  form. 
Ernst  Fuchs92  regards  metastasis  (the  germs  circulating  in  the  blood) 
or  endogenous  infection  as  the  most  frequent  cause  of  ocular  compli- 
cations met  with  in  small-pox,  scarlet  fever,  and  measles.  In  variola 
the  abscess  frequently  does  not  form  until  desiccation  is  far  advanced, 
or  even  after  patients  have  left  their  beds;  hence  they  must  be  regarded 
as  distinct  from  the  true  variola  pustule.  Metastatic  abscesses  are  met 
with  both  in  children  and  adults,  and  may  affect  both  eyes,  causing 
total  blindness.  This,  however,  should  not  be  confounded  with  small- 
pox pustules  which  develop  on  the  tarsal  conjunctiva,  generally  near 
the  intermarginal  line,  nor  with  pustules  which  form  on  the  conjunctiva 
of  the  eyeball,  near  the  limbus.  These,  it  may  be  remarked,  are  of  seri- 
ous moment,  because  they  frequently  give  rise  to  a  purulent  keratitis 
in  the  adjoining  cornea. 

Horner  further  observed,  as  true  post-variolous  affections  of  the 
eye,  diffuse  keratitis,  iritis  and  iridocyclitis,  with  opacities  in  the  vitre- 
ous humor,  and  glaucoma.  Finally,  there  may  result  extensive  sup- 
puration of  the  globe,  panophthalmitis,  leading  to  septic  infection  of 
the  choroid  and  retina,  causing  complete  loss  of  sight.  In  hnemorrhagic 
variola  haemorrhages  may  take  place  into  the  conjunctiva,  or  behind 
the  retina,  detaching  it  and  causing  blindness. 

The  Ears. — It  has  long  since  been  a  matter  of  common  observa- 
tion that  small-pox  occurring,  in  an  individual  afflicted  with  some  pre- 
existing disease  of  a  chronic  inflammatory  nature  will  exhibit  an  un- 
wonted severity  on  the  parts  thus  affected.  This  applies  to  other  organs 


92  Fuchs,  quoted  by  J.  W.  Moore  (loc.  clt.,  p.  433). 


66  THE   ACUTE    EXANTHEMATA. 

than  the  skin.  When  small-pox  supervenes  on  any  inflammatory  or 
catarrhal  affection  of  the  middle  or  internal  ear,  impairment  of  hearing 
or  actual  deafness  may  result.  This  is  usually  due  to  an  acute  or  chronic 
suppurative  otitis,  to  caries  of  the  ossicles  of  the  ear,  or  to  suppurative 
thrombosis  of  the  cerebral  sinuses.  The  latter  is,  for  the  most  part,  an 
extension  of  the  disease  from  the  middle  ear  through  the  mastoid  cells 
to  the  dura  mater.  This  may  eventuate  in  cerebral  abscesses  or  puru- 
lent embolism  of  other  organs. 

Stokes93  attributes  deafness  occurring  in  typhus  fever,  and  some- 
times following  small-pox,  to  a  paresis  of  the  auditory  nerve,  leading  to 
an  acute  degenerative  softening  of  the  intrinsic  muscles  of  the  ear.  It 
must  not  be  understood  that  these  grave  disturbances  of  the  ear  are  of 
frequent  occurrence;  on  the  contrary,  a  slight  catarrhal  condition  more 
frequently  ensues,  which,  as  health  is  restored,  completely  disappears. 

The  Nervous  System. — The  nerve-centres  are  from  the  first  affected 
by  the  variolous  poison.  Functional  disturbances  at  this  time  are  sel- 
dom absent,  while  structural  changes  are  by  no  means  uncommon.  The 
latter  may  occur  as  complications  or  sequela?.  During  the  epidemic  of 
1898-99  a  case  occurred  in  which  an  attack  of  acute  mania  set  in  early 
in  the  course  of  the  discrete  form  of  small-pox.  The  patient  had  never 
previously  suffered  from  any  brain  disturbance,  although  he  was  not 
considered  to  be  endowed  with  unusual  mental  vigor.  When  taken  to 
the  hospital  he  was  able  to  sit  up,  and,  it  is  reported,  smoked  a  cigar  on 
the  way.  The  following  day,  being  the  fourth  day  of  the  eruption,  he 
was  seized  with  a  desire  to  demolish  everything  within  reach;  so  that 
physical  restraint  was  necessary.  He  continued  violently  insane  until 
death,  which  took  place  about  six  days  later.  Whether  or  not  the  fatal 
termination  was  brought  on  by  natural  causes,  or  was  the  result  of  a 
thermometer  which  he  had  inadvertently  swallowed  before  the  attend- 
ant realized  the  serious  nature  of  his  mental  derangement,  is  not  known, 
as  an  autopsy  was  not  permitted. 

Trousseau  likewise  mentions  the  case  of  a  woman  who,  during  the 
progress  of  modified  small-pox,  was  seized  with  acute  mania  without 
any  premonitory  symptoms  of  mental  disturbance.  Three  cases  of  this 
nature  are  also  reported  by  Seppilli  and  Maragliano.94  Of  these,  one 
remained  incurably  insane,  while  the  remaining  two  recovered.  In  this 
connection  these  observers  relate  an  instance  of  a  violent  maniac  con- 
fined for  treatment  in  a  lunatic  asylum  who  was  seized  with  small-pox, 

M  Stokes  (W.),  quoted  by  J.  W.  Moore  (p.  433). 

M  Seppilli  e  Maragliano:  "Delia  Influenza  del  Vajuolo  sulla  Pazzia"  (Milano,  1878). 


VARIOLA.  67 

which  assumed  a  confluent  form.  The  disease  followed  its  usual  course, 
but  during  its  progress  the  maniacal  symptoms  subsided.  This  con- 
tinued with  the  disappearance  of  the  eruption,  and  upon  complete  re- 
covery from  the  attack  of  variola  the  patient  was  found  to  be  restored 
to  the  full  possession  of  his  mental  faculties  and  was  discharged  from 
the  asylum.  Fiessinger95  reports  a  patient  afflicted  with  acute  myelitis 
when  seized  with  variola.  After  recovering  from  the  small-pox  it  was 
observed  that  the  inflammation  of  the  spinal  cord  had  likewise  disap- 
peared. On  the  other  hand,  Stephen  Mackenzie  (quoted  by  J.  W. 
Moore)  has  recorded  a  case  of  anterior  poliomyelitis  which  followed 
variola. 

Trousseau  observed,  in  connection  with  severe  lumbar  pain  during 
the  initial  stage  of  variola,  a  slight  degree  of  paraplegia,  which  mani- 
fested itself  by  painful  numbness  and  inability  to  move  the  lower  ex- 
tremities, while  no  impairment  was  observed  in  the  arms  and  hands. 
The  bladder  is  likewise  sometimes  involved,  as  shown  by  retention  of 
urine  or  difficult  micturition.  These  paraplegic  symptoms  are,  how- 
ever, of  short  duration,  usually  terminating  with  the  eruptive  stage. 
In  rare  instances,  on  the  contrary,  they  have  been  known  to  continue 
until  the  tenth  day,  and  more  rarely  through  the  whole -attack. 

Arnaud96  has  observed  impairment  of  speech  following  an  attack 
of  variola,  while  Combemale97  has  collected  ten  cases  of  peripheral  neu- 
ritis following  variola,  all  of  which  manifested,  for  the  most  part,  diffi- 
culty in  speaking.  In  one  case — that  of  a  girl  aged  twenty,  suffering 
from  small-pox,  which  was  accompanied  by  marked  delirium  and  high 
temperature — it  was  noted  on  the  fifth  day  that  her  speech  was  affected. 
There  was  a  perceptible  slowness  in  articulation,  and  her  voice  was 
somewhat  nasal  in  character.  The  uvula  deviated  to  the  left  and  was 
insensitive.  Difficulty  was  likewise  experienced  in  framing  answers  to 
questions,  and  the  labials  and  dentals  were  badly  pronounced.  On  the 
twenty-fifth  day  the  impairment  of  speech  still  persisted,  and  the  left 
upper  lid  was  observed  to  droop.  Eecovery  finally  took  place  at  the 
end  of  two  or  three  months.  This  observer  refers  to  two  other  cases 
reported  by  Saint-Philippe,  in  which  impairment  of  speech  occurred 
quite  early  in  the  disease,  or  during  the  stage  of  infection.  In  both 
cases  there  was  difficulty  in  swallowing,  and  in  one  paraplegia  was 

88  Fiessinger:  "La  myelite  aigue  curable  dans  la  Variole."  Med.  Mod.  (Paris,  1898), 
ix,  p.  341. 

86  Arnaud:  "Troubles  de  la  Parole  consecutifs  a  la  Variole."    Marseille  Med.,  1896. 
xxxiii,  pp.  129-140. 

87  Combemale:  Archives  gen.  de  Med.,  June,  1892. 


68  THE    ACUTE    EXANTHEMATA. 

marked.  The  patients  finally  made  a  complete  recovery.  \Vhipham 
and  Meyers98  report  two  cases,  both  in  women  about  forty  years  of 
age,  in  which  impairment  of  speech  was  observed  during  the  eruptive 
stage,  together  with  loss  of  power  in  the  extremities.  These  patients 
recovered  only  incompletely  from  the  speech  affection  after  six  and  four 
years,  respectively.  Combemale  thinks  that  the  first  three  cases  were 
of  the  nature  of  paralysis  and  that  the  last  two  were  ataxic  in  character. 
According  to  this  investigator,  paralytic  disturbances  of  speech  are  com- 
mon, while  verbal  ataxia  is  rare.  He  believes  the  latter  to  be  due  to  a 
persistent  lesion  of  the  nerve-centres,  as  from  a  slight  haemorrhage, 
while  the  paralysis  he  attributes  to  the  effect  of  toxins  upon  the  periph- 
eral nerves.  Combemale  has  further  noticed  that  many  patients  speak 
with  a  nasal  twang  during  convalescence  from  variola. 

Hughlings  Jackson"  regards  many  of  these  neurotic  disturbances 
as  due  to  thrombosis  in  the  minute  vessels  of  the  medulla  oblongata. 

Westphal100  has  recorded  cases  of  small-pox  in  which  there  was 
marked  paralysis  of  the  lower  extremities  and  bladder,  which  he  be- 
lieves due  to  numerous  circumscribed  foci  in  the  gray  and  white  matter 
of  the  spinal  cord  (myelitis  disseminata).  Charcot  has  observed  a  case 
of  muscular  atrophy  of  the  arm  consecutive  to  an  attack  of  small-pox.101 

Sottas102  records  the  case  of  a  youth,  aged  eighteen,  who  contracted 
variola,  which,  although  it  assumed  a  discrete  form,  was  accompanied 
by  unusually  severe  nervous  symptoms,  which  led  his  medical  attendant 
to  fear  meningitis.  Gradually  the  patient  became  semicomatose  and 
generally  paralyzed.  His  speech  was  slow  and  dragging  rather  than 
scanning.  There  was  slight  nystagmus  without  tremor  of  the  head, 
together  with  atrophy  of  the  muscles  of  the  trunk  and  limbs,  with 
great  diminution  of  muscular  power.  These  paralytic  symptoms  grad- 
ually disappeared  and  were  replaced  by  those  of  contracture.  The  re- 
flexes became  exaggerated,  with  inco-ordination  of  voluntary  move- 
ment. Xine  months  later  he  presented  a  typical  picture  of  disseminated 
sclerosis.  He  further  remarks  that  at  this  time  there  were  no  atrophic 
disturbances  of  the  skin,  while  his  general  intelligence  suffered  and  he 
was  excitable,  impatient,  and  subject  to  violent  fits  of  rage.  Sottas 

98  Whipham  and  Meyers:  The  London  Lancet,  March  20,  1886,  p.  562. 
w  Jackson  (Hughlings),  quoted  by  J.  W.  Moore  (loc.  cit.,  p.  439). 

100  Westphal :  "Ueber  Nerven  affectionen  nach  Pocken,"  Berliner  klin.  Woch.,  1872, 
No.  1;  aiso  "Ueber  eine  Ruckenmarkserkrankheit  bei  Paraplegie  nach  Pocken,"  ibid., 
No.  47. 

101  Charcot:   "Amyotrophie  du  membre  superieur  droit,  consecutive  a  la  Variole, 
chez  un  fellah,"  N.  incog,  de  la  Salpetriere  (Paris,  1898),  xi,  p.  57. 

102  Sottas:  Gaz.  des  H6p.,  April  12,  1892,  pp.  405  et  seq. 


VARIOLA.  69 

records  the  case  as  a  typical  example  of  disseminated  sclerosis  of  in- 
fectious origin. 

The  lymphatics  are  not  infrequently  the  seat  of  disturbances  as  a 
sequela  to  small-pox.  These  are  usually  of  a  mild  nature,  although 
Hulke101*  has  observed  a  case  in  which  there  existed  a  diffuse,  radicular 
lymphangiectasis  and  lymphoma  after  a  lymphatic  abscess  which  he 
attributes  to  an  attack  of  variola. 

Affections  of  the  joints  are  likewise  sometimes,  though  rarely,  ob- 
served. They  are  usually  seen  in  strumous  subjects,  when  they  may 
prove  a  tedious,  if  not  serious,  sequela. 

The  Internal  Viscera. — Arnaud104  has  recently  given  an  admirable 
report  based  on  a  careful  study  of  the  various  diseases  of  the  internal 
viscera  following  variola.  Beraud105  has  likewise  given  in  detail  a  re- 
port of  inflammatory  affections  of  the  testicle,  and  its  analogue,  the 
ovary.  Although  almost  every  organ  of  the  body  has  been  known  to 
become  affected  by  the  small-pox  process  to  a  greater  or  less  extent, 
there  is  nothing  especially  distinctive  which  calls  for  further  considera- 
tion at  this  time. 

PATHOLOGY. 

Skin. — The  epidemic  of  variola  which  began  in  the  city  of  Cleve- 
land in  the  winter  of  1898-99  gave  excellent  opportunities  for  careful 
histological  examination  of  the  cutaneous  lesions  in  their  various 
stages,  while  a  number  of  co-existent  cases  of  varicella  supplied  valu- 
able material  for  comparison  of  the  two  diseases. 

The  material  was  examined  by  Dr.  E.  G.  Perkins  of  the  Patho- 
logical Laboratory  of  Lakeside  Hospital.  It  was  taken  during  life,  and 
placed  at  once  in  hardening  fluid,  thus  preventing,  so  far  as  possible, 
any  cell-changes  previous  to  microscopical  examination.  The  excised 
pocks  were  hardened,  some  in  Zenker's  fluid  and  some  in  a  saturated 
solution  of  corrosive  sublimate,  followed  by  a  succession  of  alcohols  of 
strengths  increasing  from  70  per  cent,  to  absolute.  Sections  were 
stained  with  eosin  and  Unna's  polychrome  methylene-blue  after  the 
usual  methods. 

The  study  of  these  cases  was  carried  on  through  the  whole  epi- 
demic, and  involved  examination  of  the  pock  in  all  stages,  from  its 
macroscopical  inception  to  the  final  separation  of  the  scab. 

103Hulke:  London  Lancet,  1893,  i,  p.  298. 

104  Arnaud:  "Lesions  viscerales  de  la  variole,"  Marseille  M6d.,  1898,  xxv,  pp.  554- 
558. 

106  Be>aud:  Archives  gen.  de  Med.,  1859,  Nos.  3  and  5. 


70  THE    ACUTE    EXANTHEMATA. 

Clinically.,  as  previously  shown,  the  course  of  the  pock  is  divided 
into  papule,  vesicle,  pustule,  and  the  formation  and  separation  of  the 
scab;  liistologically,  these  processes  run  into  each  other  more  or  less 
gradually,  and  it  is  the  height  of  each  stage,  and  not  its  beginning,  that 
gives  the  clinical  name. 

The  seat  of  the  lesion,  from  first  to  last,  is  in  the  stratum  muco- 
sum,  and  the  first  cell-changes  occur  just  below  the  stratum  corneum. 
From  this  point  the  cell-degeneration  proceeds  laterally  and  vertically, 
but  more  rapidly  in  the  former  direction,  so  that  a  section  made  vertical 
to  the  skin  surface  somewhat  resembles  a  mushroom.  Ordinarily  the 
stratum  corneum  is  not  involved  in  the  process,  but  where  it  is  of  un- 
usual thickness,  as  on  the  palms  and  soles,  the  cell-changes  are  almost 
confined  to  it. 

The  cell-changes  in  variola  and  varicella  alike  are  both  preceded 
and  accompanied  by  an  cedema,  both  intercellular  and  intracellular, 
which  varies  in  type  according  to  the  situation  and  relations  of  the 
cells  involved.  It  is  this  localized  oedema,  previous  to  any  cell-destruc- 
tion, which  gives  the  characteristic  shot-like  hardness  to  the  papule. 
With  the  progress  of  cell-degeneration  and  change  the  papular  stage 
passes  over  insensibly  into  the  vesicular.  It  is  at  this  period,  before  the 
picture  is  obscured  by  the  invasion  of  polymorphonuclear  leucocytes, 
that  the  finer  changes  in  the  pock  can  best  be  observed.  The  variation 
in  type  of  the  changes  in  the  cells  apparently  depends  on  the  thickness 
and  relative  resistance  of  the  cell-walls,  which  characters  are,  in  turn, 
dependent  on  the  age  of  the  cells  themselves.  Those  nearest  the  sur- 
face are  older,  in  process  of  preparation  for  the  stratum  corneum,  and 
have,  in  consequence,  a  more  resistant  wall  than  the  younger  cells  in 
the  deeper  parts.  In  general,  there  are,  then,  two  types  of  cell-degen- 
eration to  be  seen,  both  of  which,  as  appears  more  in  detail  below,  be- 
long to  the  general  class  of  fibrinoid  degeneration. 

In  the  more  superficial  cells  the  protoplasm  liquefies,  either  in  part 
or  as  a  whole,  leaving  a  finely  granular  albuminous  precipitate.  The 
cell-wall  and  the  nucleus  are  both  unchanged  at  this  stage,  the  latter 
lying  either  against  the  side  of  the  cell  or  being  suspended  in  its  midst 
by  fine  threads.  But  as  the  degeneration  progresses  the  nucleus  grad- 
ually loses  its  sharp  stain  and  takes  on  a  faint  fibrin-stain.  Increase  of 
pressure  leads  in  many  cases  to  rupture  of  the  cell-wall  and  the  conse- 
quent extrusion  of  the  nucleus  into  the  dilated  nutrient  canals. 

On  the  other  hand,  the  change  in  the  deeper  cells  is  of  a  different 
type;  the  entire  cell  becomes  opaque,  there  is  practically  no  differentia- 


VARIOLA.  71 

tion  between  cell-body  and  cell-wall,  and  the  consistency  of  the  cell  as 
a  whole  is  diminished,  as  may  be  seen  by  the  irregular  forms  it  take*.. 
The  protoplasm  not  infrequently  takes  a  fibrinoid  stain,  though  indi- 
vidual cells  or  small  cell-groups  may  be  found  in  which  the  protoplasm 
takes  a  very  bright  eosin  stain.  The  nuclear  changes  in  this  type  are 
also  very  characteristic.  The  nucleus  divides  into  fragments,  from  two 
to  four  in  variola,  but  as  many  as  twenty  in  varicella.  When  there  is 
doubt  as  to  the  character  of  the  fragments  they  may  be  distinguished, 
according  to  Unna,106  from  the  nuclei  of  wandering  cells  by  differential 
stains. 

During  the  process  of  the  pocks  the  exudate  varies  greatly  in 
amount  and  character.  At  first  it  consists  of  serum  only,  but  as  early 
as  the  third  day  one  finds  plasma-cells  of  all  types  in  increasing  num- 
bers. Such  early  invasion  of  plasma-cells  is  unknown  in  other  proc- 
esses, and  is  probably  to  be  ascribed  to  the  unusual  virulence  of  the  con- 
tagium.  A  few  round  cells  and  occasional  mast-cells  are  also  seen  at 
this  stage,  but  no  polymorphonuclear  leucocytes.  . 

Consequent  on  this  increasing  intercellular  exudation  there  is  a 
tendency  to  increased  elevation  of  the  surface,  and  a  general  giving  way 
in  the  direction  of  least  resistance,  as  there  has  been  no  actual  loss  of 
tissue.  In  the  deeper  layers  there  is  but  little  dilatation  of  the  chan- 
nels, but  nearer  the  surface,  where  the  cells  are  liquefied,  the  walls  are 
ruptured,  and  the  cell-remnants,  some  still  containing  pale  nuclei,  are 
pushed  together  in  septa,  which  divide  the  vesicle  into  innumerable 
microscopical  pockets,  connected  by  small  channels.  This  division  and 
subdivision  gives  rise  to  the  well-known  clinical  feature  differentiating 
variola  from  varicella,  namely:  the  extreme  difficulty  of  evacuation  of 
the  variola  pock,  while  the  varicella  pock,  being  practically  a  single 
vesicle,  is  easily  emptied. 

The  cause  of  the  umbilication  characteristic  at  this  stage  has  been 
a  fertile  source  of  discussion,  and  a  variety  of  explanations  has  been 
offered.  It  is,  of  course,  clear  that  when  the  pock  lies  about  a  hair 
the  close  adhesion  of  the  surface  epithelium  to  the  hair  stalk  may  pre- 
vent equal  expansion  of  the  surface,  and  can  thus  cause  a  central  de- 
pression. But,  in  those  cases  in  which  there  is  no  hair  in  association 
with  the  lesion,  another  cause  must  be  sought.  The  relative  amounts 
of  the  two  forms  of  epithelial  degeneration  vary  in  different  pocks.  In 


106  Unna  (P.  G.):  Orth's  "Lehrbuch  der  Spec.  Path."  (Berlin,  1894),  vol.  ii,  pp.  639 
et  seq. 


72  THE   ACUTE    EXANTHEMATA. 

some  the  central  portion  is  almost  entirely  taken  up  by  the  simple 
swelling  without  liquefaction,  while  the  edges  show  the  liquefying  form, 
and  are  consequently  more  raised.  In  other  cases  the  degeneration  at 
the  centre  appears  to  be  slower  than  at  the  periphery,  with  the  same 
result.  The  strands  or  septa  are  of  no  consequence  in  this  process,  as 
is  shown  by  the  ease  with  which  they  give  way  when  the  pock  becomes 
completely  distended  with  pus. 

The  vesicular  stage  continues  from  the  second  or  third  day  to  the 
fifth  or  sixth,  when  the  character  of  the  exudate  changes  so  markedly 
as  to  give  its  name  to  the  third,  or  pustular,  stage.  Up  to  this  point 
there  has  been  no  widening  of  blood-vessels;  on  the  contrary,  they 
appeared  small  and  scarcely  noticeable;  but  now  they  dilate,  and  a 
progressive  infiltration  with  polymorphonuclear  leucocytes  begins,  fill- 
ing out  the  pock  and  breaking  down  the  septa,  until  by  the  eighth  or 
ninth  day  sections  show  an  almost  solid  mass  of  pus-cells.  Extensive 
nuclear  fragmentation  takes  place,  affecting  the  nuclei  of  the  invading 
cells  and  plasma-cells,  as  well  as  the  already  partly  degenerated  epithe- 
lium. 

This  is  the  acme  of  the  pock.  From  this  time  on  the  changes  are 
regenerative  in  type.  About  the  tenth  day  the  pustule  begins  to  dry 
up,  either  by  a  resorption  of  the  more  fluid  elements  or  by  a  breaking 
through  of  the  stratum  corneum  and  consequent  escape  of  the  pus.  In 
either  case  a  crust  is  formed,  composed  of  all  the  tissues  which  have  un- 
dergone degeneration  as  well  as  the  remains  of  the  exudate.  This  crust 
is  slowly  pushed  off  by  new  growth  of  cells  from  all  sides,  comparable 
to  the  closing  of  an  iris-diaphragm.  A  new  stratum  corneum  is  formed 
beneath  the  crust;  so  that,  when  this  last  finally  falls  off,  the  skin  be- 
neath is  complete. 

There  is  ordinarily  no  increased  destruction  of  tissue  during  the 
pustular  stage,  but  scratching  or  secondary  infection  may  lead  to  a  pro- 
longed flow  of  pus,  and  consequently  to  increase  of  the  depth  of  the 
wound.  The  degree  of  scarring  depends  on  the  destruction  of  the 
papillae.  In  mild  cases  these  are  only  moderately  infiltrated,  and  may 
recover  to  a  great  degree,  but  in  more  virulent  cases  they  become  ex- 
tensively infiltrated  and  necrotic,  and  are  partly  cast  off  with  the  crust. 
The  new  epithelium  fails  to  fill  up  the  defect,  and  consequently  a  de- 
pression is  left. 

For  some  time  the  vessels  remain  dilated,  and  there  is  an  excess  of 
pigment  present  in  the  skin.  As  mentioned  previously,  there  is  a  dis- 
tinct variation  in  the  character  of  the  epithelial  changes  in  those  areas 


VARIOLA.  73 

where  the  stratum  corneum  is  much  thickened,  as  on  the  palms  and 
soles. 

The  epithelial  changes  have  been  a  fertile  source  of  discussions  for 
many  years,  and  no  article  can  lay  claim  to  completeness  without  some 
discussion  of  their  relative  merits. 

A  number  of  writers,  among  whom  Weigert107  is  most  conspicuous, 
consider  them  as  coming  under  the  head  of  "coagulation-necrosis." 
Against  this  idea  is  the  fact  that  the  nuclei  are  the  last  portions  of  the 
cell  to  b^  affected,  and  that  necrosis  en  masse  is  not  observed.  Xor  does 
the  "cloudy  swelling"  of  Renaut108  give  a  sufficient  description.  The 
term  is  a  very  general  one,  in  the  first  place;  and,  in  the  second  place, 
does  not  describe  the  liquefying  degeneration  at  all.  This  author,  fur- 
thermore, describes  a  "cement-substance"  between  the  individual  cells, 
which  he  considers  their  support;  but  so  far  as  the  writer  has  observed, 
there  have  been  no  confirmations  of  this  statement.  Leloir109  describes 
the  whole  process  as  alteration  cavitaire;  but  though  this  term,  which 
he  further  defines  as  liquefaction  beginning  about  the  nucleus  and 
spreading  by  degrees  throughout  the  cell,  is  a  fair  description  of  the 
changes  nearer  the  surface,  he  apparently  takes  no  account  of  the  deeper 
changes,  where  there  is  no  liquefaction,  but  the  change  takes  place  as  a 
whole.  Diphtheritic  and  croupous  changes  have  also  been  described  by 
Weigert  and  Leloir,  but  neither  of  these  came  under  observation  in  the 
present  series.  Unna  (loc.  cit.,  p.  639),  whose  work  on  the  variola  pock 
is  probably  the  most  exhaustive  yet  published,  has  endeavored  to  distin- 
guish the  two  chief  types  of  the  epithelial  degeneration  by  the  names 
of  "reticulating  colliquation,"  which  applies  to  the  changes  nearer  the 
surface,  and  "ballooning  colliquation,"  applied  to  the  deeper  changes, 
where  he  considers  the  swollen  cells  with  fragmented  nuclei  to  resemble 
small  balloons. 

The  earliest  statements  as  to  the  relation  of  the  vessel-changes  to 
the  character  of  the  exudate,  especially  as  regards  the  primary  anaemia, 
are  found  in  the  work  of  Renaut  and  Pincus.110 

Renaut  considers  this  as  a  spastic  oedema,  with  an  ectasia  of  the 
lymph-channels,  while  Pincus  ascribes  it  directly  to  the  infection. 
While  there  is  room  for  further  investigation  into  this  matter,  it  seems 
that  the  latter  view  is  right  in  the  majority  of  cases. 


107  Weigert  (C.):  Archiv  f.  Path.  Anat.,  vol.  Ixix,  p.  409. 

108  Renaut  (J.):  Ann.  de  Derm,  et  de  Syph.,  1881,  ii  S.,  ii,  p.  1. 

109  Leloir.     See  Unna  (loc.  cit.,  p.  645). 

110  Pincus.     See  Unna  (loc.  cit.). 


74  THE   ACUTE    EXANTHEMATA. 

Careful  examination  of  the  sections  with  approved  bacterial  stains 
fails  to  demonstrate  any  bacteria  at  any  stage  previous  to  the  rupture 
of  the  stratum  corneum.  After  this  it  is  not  uncommon  to  find  cocci 
and  streptococci  in  abundance,  but  only  in  the  crust,  not  in  the  epithe- 
lium. The  figures  in  the  epithelial  cells  usually  in  the  immediate  vicin- 
ity of  the  nucleus  have  been  discussed  exhaustively  by  writers  in  all 
countries. 

Guarnieri,111  Pfeiffer,112  Clarke,113  and  many  others,  put  them  in 
the  class  of  protozoan  parasites,  though  they  have  reached  no  definite 
agreement  as  to  finer  classification.  To  the  present  writer  the  work  of 
Hiickel,114  who  has  made  an  exceedingly  careful  study  of  the  subject, 
with  an  unusual  wealth  of  experimental  material,  seems  to  be  conclu- 
sive. In  his  general  summary  he  says:  "My  results  are  both  negative 
and  positive:  negative  as  far  as  they  fail  to  explain  the  natural  manner 
of  the  contagium;  positive  in  so  far  as  they  show  that  in  inoculations 
of  the  cornea  with  vaccine  there  is  at  the  point  of  inoculation  a  certain 
portion  of  the  cell-body  of  the  epithelium  which  is  affected  in  a  definite 
manner.  The  characteristic  pictures  thus  caused,  due  to  as  yet  un- 
known structural  properties  of  the  cytoplasm,  are  direct  results  of  these 
properties,  and  are  not  the  parasitic  protozoa  of  vaccine,  as  the)'  have 
been  described.  It  is  not  essential  that  the  contagium  should  develop 
in  the  epithelial  cell  itself  to  explain  the  occurrence  of  the  vaccine 
bodies.  The  cause  may  very  well  lie  solely  in  the  action  of  a  toxin  re- 
sulting from  a  contagium  which  occurs  and  increases  extracellularly. 
Yet  it  must  be  admitted  as  possible  that  the  contagium — over  whose 
general  and  local  action  we  are,  indeed,  informed,  but  whose  nature 
and  morphology  is  as  yet  entirely  unknown — contained  in  the  epithe- 
lium cells  themselves  and  especially  in  the  vaccine  bodies,  though 
doubtful  as  to  development  and  increase,  may  be  directly  bound  to  the 
protoplasm.  Perhaps  the  contagium  is  so  minute  that  its  perception 
with  the  existing  optical  facilities  and  microscopical  and  cultural  meth- 
ods may  be  impossible." 

In  this  connection  the  recent  work  of  Eoux  and  Xocard115  is  of  the 
greatest  interest.  They  were  unable  to  cultivate  or  even  see  the  or- 
ganism which  they  suspected  to  be  the  cause  of  pleuro-pneumonia  in 
cattle,  until  they  made  use  of  the  technique  introduced  by  Metchni- 

111  Guarnieri  (G.):  Archiv.  per  la  Scienze  Med.,  1892,  xvi,  pp.  40  et  seg. 

112  Pfeiffer  (L.):  Monats.  f.  Prak.   Derm.,  1887,  vi.  p.  589. 

114  Clarke  (J.  J.):  Cent.  f.  Bact.  u.  Parasit.,  1895,  vol.  xviil,  p.  300. 

u«Httckel:  Ziegler's  Beitrage,  1898,  II  Supplement. 

118  Roux  and  Nocard:  Ann.  de  1'Inst.  Pasteur,  April,  1898. 


VAKIOLA.  75 

koff.116  Thin-walled  sterile  sacs  of  collodion  were  made,  filled  with 
a  few  cubic  centimetres  of  bouillon,  inoculated  with  the  suspected  fluid, 
which  was  taken  with  full  precautions  against  contamination,  and  these 
sacs  were  placed  in  the  peritoneal  cavities  of  rabbits,  guinea-pigs,  calves, 
etc.  The  collodion  prevented  entrance  of  cells  or  exit  of  bacteria,  but 
acted  as  an  osmotic  membrane,  enabling  the  fluids  within  and  without 
to  freely  interchange.  The  results  were  most  satisfactory  and  showed 
the  presence  of  organisms  in  inoculated  sacs,  which  did  not  occur  in  the 
sterile  control  sacs.  Again,  these  organisms  were  so  excessively  minute 
that  a  magnification  of  two  thousand  diameters  was  necessary  to  see 
them  at  all,  and  even  with  this  power  their  form  could  not  be  made 
out.  Copeman,117  in  his  search  after  the  organism  of  vaccine,  inocu- 
lated eggs,  which  he  kept  in  the  thermostat  for  varying  lengths  of  time, 
and  claims  to  have  found  in  them  a  small  bacillus  which  would  not  grow 
on  ordinary  media.  But  his  experiments  were  not  sufficiently  complete 
to  establish  either  the  impossibility  of  contamination  or  the  identity 
of  his  organism  with  the  contagium  of  vaccine.  More  recently  K. 
Nakanishi118  has  isolated  and  studied  a  bacillus,  which  he  finds  con- 
stantly present  in  the  vaccine  pustules  of  children  and  calves,  and  to 
which  he  has  given  the  name  bacillus  varidbilis  hjmplice  raccinalis. 
Biologically  this  organism  shows  a  great  variation  in  form  and  size,  and 
is  classified  by  Xakanishi  as  belonging  to  the  group  diphtheria?  or 
pseudodiphtheria  bacilli. 

Morphologically  five  chief  forms  may  be  distinguished.  Intra- 
peritoneal  injections  of  bouillon  cultures  proved  fetal  in  three  rabbits 
out  of  five,  with  a  moderate  ha?morrhagic  exudate  into  the  abdominal 
cavity;  but  the  most  interesting  changes  were  seen  in  those  .rabbits 
inoculated  upon  the  cornea.  In  these  cases,  following  a  moderately 
deep  inoculation,  there  developed  corneal  epithelial  cells,  which  con- 
tained in  their  protoplasm,  in  the  neighborhood  of  the  nucleus,  one  to 
three  round,  or  rod-like,  bodies  of  various  size,  which  appeared  identical 
with  the  cytorryctes  variola?  of  Guarnieri.119  While  not  affirming  posi- 
tively, in  the  absence  of  definite  proof,  the  etiological  relationship  of 
this  bacillus  variabilis  lymphge  vaccinalis,  Nakanishi  believes  that  it  is 
the  causative  factor  in  vaccinia  and  variola. 

In  this  connection  it  is  interesting  to  note  that  Levy  and  Finkler,120 


118  Metchnikoff  (E.):  Ann.  de  1'Inst.  Pasteur,  1899,  xi,  p.  245. 

117  Copeman  (S.  M.):  The  Lancet,  1895,  p.  370. 

118  Nakanishi  (K.):  Cent.  f.  Bact.  u.  Parasit.  u.  Infect.,  1900,  vol.  xxvii,  May  26th. 

119  Guarnieri  (G.):  Loc.  cit. 

120  Levy  and  Finkler:  Deutsche  med.  Woch.,  June  28,  1900. 


76  THE    ACUTE    EXANTHEMATA. 

working  independently,  have  isolated  a  bacillus  called  by  them  conjne- 
bacterium  lymphce  vaccinalis,  which  is  apparently  identical  with  the  ba- 
cillus described  by  Nakanishi.  In  conclusion  they  say:  "Morpho- 
logically and  culturally  our  bacillus  belongs  to  the  diphtheria-bacillus 
group,  or  more  correctly  to  that  group  designated  as  'pseudodiph- 
theria.'  We  have  assigned  it,  on  account  of  its  branching,  club-shaped, 
and  round  forms,  to  the  great  group  of  the  actinomycetes,  and  more 
specifically  to  the  genus  corynebacterium  of  Lehman  and  Xeumann." 
The  etiological  significance  of  this  bacillus  remains  an  open  question. 
These  experiments  give  hope  that  in  the  future,  provided  that  such 
organisms  are  not  beyond  the  power  of  human  vision,  we  may  find  the 
character  of  the  contagium  of  variola,  as  well  as  that  of  many  other 
infectious  diseases  hitherto  undiscovered. 

Mucous  Membranes. — After  death  the  mucous  membranes  are 
found  involved  to  a  less  degree  than  the  skin.  Those  which  are  most 
exposed  to  the  external  air  at  the  various  orifices  of  the  body,  as  has 
been  previously  shown,  seldom  escape,  and  often  present  well-defined 
variola  lesions,  while  the  general  mucosae  of  the  respiratory  and  digest- 
ive tracts  may  show  no  traces  of  infection,  even  when  the  integument  is 
thickly  studded  with  pocks.  An  autopsy  made  at  the  Cleveland  Small- 
pox Hospital  showed  the  mucosae  entirely  free,  although  fully  a  third  of 
the  cutaneous  surface  was  covered  with  small-pox  lesions.  At  other 
times  there  are  only  evidences  of  congestion  in  various  parts,  while,  in 
some,  what  appears  to  be  secondary  pus-infection  giving  rise  to  diffuse 
or  circumscribed  purulent  infiltration  of  the  mucosae  may  be  detected. 
Curschmann  describes  catarrhal,  croupous,  or  diphtheritic  inflamma- 
tion and  diffuse  purulent  infiltration  of  the  middle  epithelial  layer. 

It  may  be  stated  as  a  rule  that  the  changes  in  the  mucous  mem- 
branes are  in  direct  relation  to  the  extent  and  intensity  of  the  cutaneous 
lesions.  In  confluent  small-pox  pustules  are  frequently  found  in  the 
trachea  as  far  as  its  bifurcation,  and  Wagner  has  seen  them  in  the  sec- 
ond and  third  branches  of  the  bronchial  tubes.  In  the  haemorrhagic 
forms  there  are  likewise  marked  evidences  of  congestion,  and  yellowish 
exudation,  with  an  abundance  of  bloody  mucus,  is  seen.  When  death 
takes  place  late  in  the  course  of  variola,  terminal  pneumonia  and  acute 
pulmonary  tuberculosis  are  not  infrequently  found.  Similar  changes 
are  often  observed  in  the  gastro-intestinal  tract.  Pustules  may  be  found 
in  the  upper  portion  of  the  trachea  and  in  the  lower  part  of  the  rectum, 
with  catarrhal  inflammation  and  small  haemorrhages  in  the  stomach 
and  intestines.  Sometimes  the  mesenteric  glands  swell  and  the  intes- 


VARIOLA.  77 

tinal  follicles  suppurate.  This  may  be  mistaken  for  true  variola  pust- 
ules, which  are  occasionally  observed.  I  am  not  aware  that  pustules 
have  ever  been  found  in  the  bladder,  and  the  urethra  seems  likewise 
to  enjoy  complete  immunity.  There  are  evidences,  even  during  life, 
of  congestion  of  the  urinary  tract,  and  pustules  sometimes  occur  at  the 
meatus  urinarius. 

Serous  membranes,  according  to  my  observation,  are  even  less 
prone  to  become  implicated  than  the  mucous  surfaces.  In  haemor- 
rhagic  small-pox,  ecchymoses  and  extensive  ha?morrhages  are  found 
both  in  the  mucous  and  serous  membranes,  as  well  as  in  the  stomach  and 
in  the  loose  connective  tissue  of  the  thoracic  and  abdominal  cavities. 

The  morbid  anatomy  of  the  internal  viscera  has  been  studied  by 
Ponfick,  Osier,  Siderey,  Laure,  and  others. 

Internal  Viscera.  —  The  morbid  changes  have  principally  been 
found  in  the  liver,  spleen,  and  kidneys.  The  period  at  which  death 
takes  place,  rather  than  the  form  of  variola  present,  accounts  for  the 
differences  noted.  In  haemorrhagic  variola,  however,  especially  the  pur- 
puric  A'ariety,  the  viscera  are  found  engorged  with  blood  and  otherwise 
but  little  changed,  on  account  of  the  rapid  termination  of  the  disease. 

When  death  occurs  later,  as  in  variola  vera,  the  liver  and  kidneys 
are  swollen  and  present  granular  or  fatty  degeneration,  sometimes  re- 
sembling that  produced  by  phosphorus  poisoning.  The  contents  of  the 
gall-bladder  are  usually  pale  and  thinner  than  normal  bile. 

During  the  early  stages  of  variola  vera  Ponfick121  has  observed  the 
spleen  greatly  enlarged  and  its  parenchyma  soft  and  of  a  light  color, 
while  in  purpuric  variola  it  is  small  and  of  a  dirty  or  dark-red  color, 
with  large  white  or  yellowish  follicles.  Later  in  variola  vera  the 
spleen  not  infrequently  appears  unchanged.  When  the  fatty  degen- 
eration of  the  liver  and  kidneys  is  far  advanced,  the  heart-walls  are  yel- 
low, flabby,  and  brittle.  In  purpuric  variola,  on  the  contrary,  the  heart 
has  been  found  to  be  contracted,  firm,  and  brownish  red.  The  brain  and 
spinal  cord  are  usually  but  little  changed,  although  they  may  be  con- 
gested and  cedematous. 

The  Blood. — In  haemorrhagic  small-pox  it  was  formerly  supposed 
that  the  bleeding  occurred  from  an  infective  dissolution  of  the  blood, 
or  haematolysis.  Klebs122  and  Unna  (loc.  cit.),  however,  explain  the 
haemorrhagic  process  as  one  of  bacterial  thrombosis  in  which  the  blood- 
channels  of  the  skin,  in  common  with  other  organs,  are  blocked  with 

m  Ponfick  (E.):  Berliner  klin.  Woch.,  1872,  No.  42. 

122  Klebs  (E.):  Handbuch  der  Path.  Anat.   (Berlin,  1868-80),  v,  i,  p.  40. 


78  1HE    ACUTE    EXANTHEMATA. 

bacteria,  causing  coagulation  and  consequent  diapedesis  into  the  sur- 
rounding parts.  The  pathological  difference  between  the  purpuric  and 
ha?morrhagic  varieties  is  one  of  degree  only.  In  the  former  diapedesis, 
or  acute  ha?matophilia,  is  established  at  the  onset  and  death  takes  place 
during  the  initial  stage,  while  in  the  latter  it  occurs  during  the  devel- 
opment and  maturation  of  the  pustules. 

After  death  the  dark-purple  spots  and  extensive  ecchymoses  re- 
main unchanged. 

According  to  Weil,123  variola  is  generally  accompanied  by  leuco- 
cytosis,  which  is  a  mononucleosis  of  large  granulated  or  non-granulated 
myelocytes:  the  mother-cells  of  the  normal  leucocytes  in  the  blood. 
This  type  of  leucocytosis  has  been  noted  in  myelogenic  leukaemia  alone, 
and  it  shows  an  interesting  analogy  between  leukaemia  and  variola, 
which  also  affects  the  bone-marrow.  Nucleated  red  corpuscles  may  also 
appear  in  the  circulation;  they  are  constant  in  the  haemorrhagic  forms, 
with  1  normoblast  to  100  leucocytes,  and  possibly  25  per  cent,  of  neu- 
trophile  mononucleated  cells.  The  pus  of  the  pustules  contains  the 
same  variety  of  leucocytes  found  in  the  blood,  and  consequently  the 
suppuration  is  evidently  an  integral  part  of  the  variolar  infection.  The 
differentiation  of  variola  is  possible  at  an  early  stage  by  the  study  of 
the  blood;  the  only  eruptive  disease  resembling  it  is  varicella,  in  which 
a  mononucleosis,  though  in  less  degree,  also  occurs. 

ETIOLOGY. 

Following  the  prevailing  trend  of  pathology  in  various  epochs  of 
medical  history,  small-pox  has  been  ascribed  to  various  influences.  At 
one  time  it  was  supposed  to  be  due  to  emanations  from  decomposing 
matter,  again  to  special  climatic  conditions.  With  the  advent  of  or- 
ganic chemistry  and  its  important  revelations  early  in  the  nineteenth 
century,  it  was  fully  expected  that  the  causa  causans  of  variola  would 
be  revealed.  We  of  the  present  day  believe  that  with  the  future  devel- 
opment of  bacteriology  the  etiology  of  small-pox,  together  with  other 
infectious  diseases,  will,  in  the  near  future,  be  made  clear.  We  have 
elsewhere  shown  that  the  disease  is  well-nigh  co-existent  historically, 
with  the  human  race,  and  is  encountered  over  the  entire  globe.  Neither 
climate,  soil,  nor  race  seems  to  influence  its  spread,  and,  like  many  other 
infectious  diseases,  its  first  appearance  among  primitive  peoples  is 
marked  by  great  severity. 

Season  of  the  Year. — This  has  a  marked  influence  on  the  develop- 

128  Weil  (E.):  Presse  Med.,  June  27,  1900. 


VARIOLA.  79 

ment  of  variola.  In  the  United  States,  Canada,  and  Europe  small-pox 
is  more  prevalent  during  the  late  autumn,  winter,  and  early  spring 
months,  while  during  the  summer  it  usually  occurs  only  in  sporadic 
cases,  if  at  all. 

In  the  general  epidemic  of  1898-1901,  as  observed  in  Ohio,  the  dis- 
ease began  with  a  few  sporadic  cases  during  the  summer,  and  as  cold 
weather  set  in  it  spread  more  or  less  generally  throughout  the  State. 
During  the  cold  months  the  disease  gradually  extended  and  did  not 
entirely  disappear  until  the  summer  had  well  advanced.  During  the 
past  eighteen  years  cases  of  small-pox  in  the  city  of  Cleveland  have 
been  extremely  rare  during  the  summer  months,  and  no  epidemics  have 
occurred  at  this  time,  while  during  the  winter  months  small-pox  epi- 
demics of  more  or  less  severity  have  occurred  at  frequent  intervals.  In 
tropical  countries,  where  small-pox  is  more  prevalent  at  the  present 
time  than  in  the  temperate  zone,  the  opposite  holds  true,  the  disease 
being  more  prevalent  daring  the  hot  weather  and  ameliorated  by  heavy 
rain-falls  or  during  the  months  of  a  tropical  winter.  Opinions  differ  as 
to  whether  the  deficient  ventilation  occasioned  by  cold  weather  is 
responsible  for  this  increased  prevalence.  At  any  rate,  it  is  highly 
probable  that  ill-ventilated  apartments  tend  to  increase  the  danger  of 
infection.  It  has  been  shown  by  J.  W.  Moore  (loc.  cit.)  that  in  northern 
Europe  the  disease  thrives  best  when  the  temperature  is  below  50°  F. 
This,  according  to  my  observation,  likewise  holds  good  in  Xorth 
America. 

Age. — Before  the  introduction  of  vaccination,  small-pox,  like  scar- 
let fever  and  measles,  was  essentially  a  disease  of  childhood.  Being 
susceptible,  the  child  generally  contracted  the  disease  at  an  early  age, 
which  conferred  immunity  against  a  second  attack  for  the  rest  of  life. 
When  the  disease  first  appears  in  a  country,  however,  all  ages  are  equally 
attacked.  Since  the  introduction  of-  vaccination  the  proportion  of 
adults  who  contract  small-pox  is  greater  than  that  of  children,  because 
children  are  usually  vaccinated,  thus  affording  immunity  for  a  number 
of  years.  Eevaccination  is  less  generally  performed,  which  renders  a 
greater  number  of  people  susceptible  to  the  disease  in  adult  life.  Of 
763  cases  of  small-pox  reported  to  the  Ohio  State  Board  of  Health  dur- 
ing the  winter  of  1898-99,  66  per  cent,  were  in  adults.  Statistics  show 
that  previous  to  the  end  of  the  eighteenth  century  small-pox  was  largely 
a  disease  of  children.  A  moment's  thought  will  show  that  this  must  be 
so  in  any  disease  so  contagious  as  small-pox;  most  children  being  liable 
to  it,  and  unprotected,  contract  it  at  an  early  age,  whereas  most  adults 


80  THE    ACUTE    EXANTHEMATA. 

have  had  a  certain  degree  of  immunity  conferred  by  an  attack  of  small- 
pox in  childhood. 

In  Chester,  England,  for  instance,  in  the  spring  of  1774,  202 
deaths  occurred  from  small-pox,  all  of  the  patients  being  under  10 
years  of  age  and  a  quarter  of  them  being  under  1  year.  In  Kilmarnock, 
of  622  deaths  which  occurred  between  1728  and  1763,  only  7  were  of 
patients  above  10  years  of  age;  and  in  Edinburgh  between  the  years  of 
1764  and  1783,  993  out  of  every  1000  who  died  of  small-pox  were  under 
10  years  of  age.  Statistics  show  clearly  that  this  record  of  the  eight- 
eenth century  is  reversed  under  compulsory  vaccination  laws.  Children 
very  generally  escape,  adults  furnishing  much  the  larger  proportion  of 
cases  attacked.  The  inference  is  unavoidable  that  revaccination  is 
almost  as  urgently  needed  as  is  the  vaccination  of  children.  According 
to  some  writers,  infants  at  the  breast  are  less  susceptible  than  those  of 
a  year  or  more  of  age.  This,  however,  I  have  been  unable  to  confirm. 
The  disease,  moreover,  occurs  in  intra-uterine  life,  as  has  been  fre- 
quently observed.  Curschmann  found  evidences  of  a  small-pox  erup- 
tion in  a  foetus  of  five  months,  and  in  one  instance  I  have  observed 
what  appeared  to  be  a  variolous  eruption  in  a  foetus  between  the  fourth 
and  fifth  month  whose  mother  was  afflicted  with  variola. 

Sex  has  no  appreciable  influence,  although  in  the  reports  of  the 
Metropolitan  Asylum  of  London  males  are  slightly  in  excess.  This, 
doubtless,  arises  from  greater  exposure,  their  vocations  bringing  men 
in  contact  with  the  small-pox  contagium  more  frequently  than  women, 
who  remain  more  at  home. 

Pregnancy  does  not  predispose  to  the  disease,  neither  does  the  gen- 
eral state  of  health  appear  to  exert  any  influence.  On  the  contrary, 
strong  adults  seem  to  furnish  a  large  contingent  of  small-pox  patients. 

Race. — It  is  generally  believed  that  the  African  race  is  more  sus- 
ceptible to  small-pox'than  the  European,  and  that  the  dark-skinned  are 
more  susceptible  than  the  Caucasian.  From  personal  observation  I  am 
inclined  to  attribute  this  to  the  unhygienic  surroundings  of  the  African 
more  than  to  any  racial  predisposition  per  se.  Neither  have  I  been 
able  to  observe  any  marked  severity  in  those  attacked.  The  native  In- 
dians of  America  are  especially  prone  to  the  disease.  From  its  first 
introduction  by  the  Spaniards  to  the  present  time,  whole  communities 
and  tribes  of  Indians  have  been  completely  obliterated  by  its  invasion. 
With  them  it  seems  to  thrive  with  the  thermometer  40°  F.  below  zero 
as  readily  as  in  the  tropics.  Again,  their  mode  of  living  favors,  in  a 
high  degree,  the  spread  of  infectious  diseases  when  introduced  among 


VARIOLA.  81 

them.  All  persons  do  not  manifest  in  an  equal  degree  a  predisposition 
to  variola  nor  is  the  same  person  equally  susceptible  at  all  times.  Nu- 
merous instances  are  recorded  in  which  small-pox  finally  developed 
months  after  repeated  exposure  to  the  disease  had  occurred. 

Association  with  Other  Diseases. — The  frequent  occurrence  of  the 
prodromal  rash  in  variola  and  its  close  resemblance  to  the  other  exan- 
thematous  affections  has  doubtless  given  rise  to  the  belief  that  small- 
pox not  infrequently  is  accompanied  by  either  scarlatina  or  measles. 
Curschmann,  whose  extensive  observations  have  enabled  him  to  con- 
tribute most  exhaustively  on  this  subject,  says:  "In  the  hospital  at 
Mayence  convalescents  from  typhoid  fever  sometimes  contracted  small- 
pox from  the  adjoining  small-pox  ward,  and  rarely  small-pox  has  fol- 
lowed convalescence  from  other  exanthematous  affections,  but  it  is 
extremely  doubtful  if,  during  the  height  of  these  diseases,  small-pox 
can  be  contracted."  MacCombie124  in  his  extensive  experience  with 
small-pox  has  not  seen  a  single  instance  of  the  co-existence  of  small- 
pox with  any  of  the  acute  infective  eruptive  diseases.  I  have  never 
encountered  variola  in  connection  with  the  other  exanthemata,  al- 
though it  has  been  observed  to  occur  in  connection  with  syphilis,  acne, 
eczema,  psoriasis,  and  other  affections  of  the  skin.  Variola  in  syphilis 
has,  in  my  observation,  always  pursued  a  mild  course,  although  I  am 
not  prepared  to  attribute  any  protective  influence  to  this  condition,  as 
in  every  case  the  patient  claimed  to  have  been  previously  vaccinated. 
In  one  instance,  that  of  a  negro,  who  entered  the  hospital  with  second- 
ary syphilis,  there  seemed  to  be  complete  immunity  to  small-pox  infec- 
tion, until  some  months  after  entering  he  was  inoculated  by  an  at- 
tendant, which  in  due  time  gave  rise  to  a  mild  attack  of  variola. 

M*ode  of  Infection. — Although,  as  previously  shown,  the  contagious 
nature  of  variola  had  been  recognized  at  a  very  early  period,  to  Boer- 
haave,125  of  Leyden,  we  are  indebted  for  a  clearer  description  of  the  dis- 
ease and  its  mode  of  propagation  than  had  heretofore  been  given.  The 
present  state  of  our  knowledge  justifies  us  in  assuming  from  analogy 
that  the  active  principle  in  causing  small-pox  is  a  micro-organism  which 
exists  in  the  vesicles,  pustules,  crusts,  and  is  probably  carried  off  by 
currents  of  air;  so  that  infection  may  take  place  at  some  distance  from 
the  body.  Inoculations  of  blood,  urine,  and  saliva  from  small-pox  pa- 


124  MacCombie   (J.):    "Small-pox"  in   "Allbutt's  System  of  Medicine"    (New  York, 
1897),  vol.  iii,  p.  212. 

128  Van  Sweiten:  "Commentaria  in  H.  Boerhaave  Aphorismos,"  tome  v,  Lugd.  Bat. 
1772. 

6 


82  THE   ACUTE    EXANTHEMATA. 

tients  have  been  made  with  a  negative  result,  although  these  investiga- 
tions cannot  be  regarded  as  conclusive.  On  the  contrary,  it  is  highly 
probable  that  the  blood  of  small-pox  patients  contains  the  virus  in  a 
high  degree.  The  usual  mode  of  infection  is  directly  from  person  to 
person,  although  mediate  infection  from  a  third  person,  or  from  cloth- 
ing, infected  rooms,  bedding,  books,  rags,  etc.,  is  not  infrequent.  It 
has  been  found  that  even  during  the  prodromal  stage  infection  is 
possible,126  although  it  is  during  the  eruptive  stage  that  the  disease  is 
usually  communicated.  The  period  of  greatest  danger  from  direct  ex- 
posure is  during  the  pustular  and  desquamative  stages.  At  this  time 
entering  the  room  is  sufficient  to  communicate  the  disease.  The  size  of 
the  room  and  the  number  of  patients  therein  naturally  determine  the 
danger  of  infection.  Likewise,  increasing  the  distance  from  the  focus 
of  infection  lessens  the  danger  of  infection.  A  patient  is  not  to  be  con- 
sidered free  from  danger  until  all  crusts  and  scales  have  disappeared, 
when,  after  thorough  cleansing  of  the  body  and  disinfection  of  the 
clothing,  he  may  be  considered  inocuous.  The  virus  retains  its  con- 
tagious property  for  a  long,  though  indefinite,  time.  According  to 
Buck,127  undoubted  instances  are  recorded  of  the  virus  remaining  active 
from  one  to  two  years.  Excluding  a  free  circulation  of  air  favors  this 
maintenance,  while  it  is  extremely  doubtful  if  the  virus  remains  active 
when  suspended  for  a  short  time  in  the  open  air. 

The  aerial  distribution  of  small-pox  has  of  late  received  much  at- 
tention. Some — with  Power,128  Barry,129  and  Evans130 — have  en- 
deavored to  prove  that  the  infection  of  districts  surrounding  small-pox 
hospitals  bears  an  inverse  ratio  to  the  distance  from  the  focus  of  con- 
tamination; while  Savill,131  Seaton,132  and  others  believe  that  aerial 
currents  are  not  an  appreciable  factor  in  the  diffusion  of  small-pox. 


124  Schafer  relates  (Deutsche  Militairarztl.  Zeit.,  1872,  p.  53)  an  instance  of  trans- 
mission of  small-pox  during  the  latent  stage.  Skin  from  a  recently-amputated  arm  was 
employed  in  the  Charite  Hospital  of  Berlin  for  transplantation  on  other  individuals. 
At  the  time  of  amputation  the  patient  appeared  to  be  free  from  small-pox  infection,  but 
some  hours  later  was  seized  with  the  premonitory  symptoms  of  the  disease,  which  was 
followed  in  due  course  by  the  small-pox  eruption.  Of  those  on  whom  the  transplanted 
skin  had  been  placed,  one  was  attacked  six  days  later 'with  small-pox,  while  the  others 
remained  free. 

127  Buck  (A.  H.):  "Treatise  on  Hygiene"  (New  York,  1879),  vol.  ii,  p.  519. 

iz8  power  (W.  H.):  "Supplement  to  the  Local  Government  Board's  Annual  Report" 
(London,  1880-81;  also  1884-85-86). 

128  Barry  (F.  W.):  "Report  of  an  Epidemic  of  Small-pox  at  Sheffield,  1887-88"  (Lon- 
don, 1889). 

180  Evans  (A.):  Brit.  Med.  Jour.,  1894,  ii,  pp.  356-358. 
m  Savill  (T.  D.):  Brit.  Med.  Jour.,  1897,  ii,  p.  1680. 
182  Seaton  (E.):  Brit.  Med.  Jour.,  1896,  i,  p.  582. 


VARIOLA. 


83 


Barry  found  a  noticeable  increase  in  the  number  of  dwellings  infected 
which  were  situated  within  4000  feet  of  a  small-pox  hospital.  This  he 
reduced  to  mathematical  precision  in  the  accompanying  diagram. 
Similar  observations  are  given  by  Evans  in  the  epidemic  of  1893  at 
Bradford.  It  was  observed  that,  between  January  14th  and  December 
30th,  626  dwellings  situated  within  a  mile  of  the  small-pox  hospital 

4000  ft 


Diagram  showing  the  Influence  of  the  Sheffield  Hospital  in  Spreading 
the  Disease  in  1887-88.     (Taken  from  J.  W.  Moore.) 

were  invaded  by  the  disease.  The  percentage  for  the  whole  borough 
outside  the  mile  area  was  0.6,  while  within  the  mile  radius  it  was  3.6  per 
cent.  He  further  estimated  the  percentage  within  a  quarter-of-a-mile 
radius  to  be  10.4,  between  a  q^^arter  and  a  half  mile,  6.8;  between  half 
and  three-quarters  of  a  mile,  2.1;  and  only  1.0  per  cent,  for  houses 
situated  between  three-quarters  and  one  mile  from  the  hospital. 

Aerial  currents  are  likewise  shown  to  influence  the  spread  of  the 


84  THE    ACUTE    EXANTHEMATA. 

disease  in  question.  Thus,  it  was  observed  that  a  larger  proportion  of 
houses  (7.06  per  cent.)  became  newly  invaded  on  the  northeast  side  of 
the  hospital,  while  the  corresponding  quadrant  on  the  southwest  side 
was  affected  least  of  all,  showing  a  percentage  of  only  2.93  per  cent., 
the  prevailing  winds  being  from  the  southwest.  Savill,  on  the  contrary, 


Diagram  showing  the  Influence  01  Wind  in  Disseminating  Small-pox. 
(Taken  from  J.  W.  Moore.) 

in  observing  the  diffusion  of  small-pox  in  two  buildings  in  which  there 
were  1076  persons  adjoining  a  small-pox  hospital,  ascertained  that  in 
10  only  was  the  source  of  infection  other  than  direct  exposure  or  con- 
tact. The  epidemic  continued  nine  months,  and  in  concluding  his  ob- 
servations he  remarks  that  the  air,  being  a  bactericide  in  itself,  he  does 
not  believe  that  the  small-pox  poison  is  infectious  beyond  the  confines 


.  85 

of  a  rooiri.  Seaton  quotes  Billings  to  the  effect  that  a  collection  of 
small-pox  cases  may  be  so  managed  as  to  prevent  the  diffusion  of  spe- 
cifically-infected dust  to  surrounding  dwellings,  although  in  this  coun- 
try it  is  customary  to  locate  small-pox  hospitals  away  from  thickly- 
populated  districts.  In  Cleveland  the  Small-pox  Hospital  is  situated 
about  eight  or  nine  miles  from  the  city  in  a  rather  thickly  settled  farm- 
ing community.  The  prevailing  winds,  which  are  from  the  west  and 
northwest  during  the  winter  months,  carry  the  dust  from  the  small-pox 
hospital  toward  two  dwellings  situated  less  than  half  a  mile  from  the 
hospital.  For  seven  months  the  hospital  was  crowded,  during  which 
time  observations  were  made,  yet  no  instance  of  conveyance  by  the  air 
was  or  has  since  been  reported.  With  proper  precautions  against  the 
accumulation  of  dust  and  other  debris,  it  seems  highly  probable  that  the 
danger  from  aerial  infection  is  but  slight,  and  that  dwellings  situated 
a  quarter  of  a  mile  or  less  from  small-pox  hospitals  may  be  considered 
free  from  danger. 

DIAGNOSIS. 

In  typical  cases  of  small-pox  little  difficulty  need  be  experienced 
in  arriving  at  a  correct  diagnosis,  the  appearance  of  the  disease  being 
so  striking  and  many  of  the  symptoms  so  distinctive  that  when  once 
seen  they  cannot  well  be  mistaken.  In  former  times  the  principal  ob- 
stacle to  diagnosis  lay  in  the  severity  of  the  disease,  while  to-day  the 
mild  nature  of  the  affection,  as  frequently  encountered,  gives  rise  to  the 
main  difficulties  in  its  recognition. 

During  Sydenham's  time  the  black  death  gathered  in  its  countless 
thousands,  even  before  the  first  distinguishing  features  of  small-pox  ap- 
peared. With  the  advent  of  vaccination,  and  possibly  of  better  hygienic 
conditions,  much  of  its  old-time  severity  has  passed  away,  although  the 
problem  of  differential  diagnosis  still  remains  the  bete  noire  of  many 
practitioners. 

The  most  important  time  to  recognize  the  disease  is  at  the  onset,  as 
it  is  at  this  time  that  uncertainties  of  diagnosis  are  most  liable  to  occur. 
During  the  past  three  winters  excellent  opportunities  to  study  small- 
pox have  occurred  in  Cleveland.  In  observing  cases  entering  the  Small- 
pox Hospital  one  was  impressed  with  the  fact  that  in  many  instances 
the  disease  was  well  under  way  before  the  patient  was  received.  Upon 
inquiry  it  was  ascertained  that  in  most  cases  an  uncertain  diagnosis  had 
occasioned  the  delay.  It  is  also  an  unfortunate  fact  that  a  mistaken 
kindness — a  too  tender  regard  for  the  feelings  of  the  patient  and  his 


86  THE    ACUTE    EXANTHEMATA. 

immediate  family — deterred  medical  men  from  reporting  suspected 
cases.  It  is  not  strange,  therefore,  that,  in  spite  of  the  efforts  of  the 
health  department,  the  epideniic  insidiously  extended  until  its  victims 
within  a  few  months  were  numbered  by  the  hundreds.  Much  contro- 
versy likewise  arose  as  to  the  diagnosis  of  individual  cases,  because 
typical  landmarks  were  sometimes  wanting.  Thus,  it  may  be  argued 
that  the  eruption  is  not  one  of  variola  because  umbilication  is  not  pres- 
ent; again,  that  the  eruption  does  not  develop  in  regular  order  from 
the  shot-like  indurations  in  the  skin  to  vesicles,  which  remain  from  one 
to  two  days  and  go  on  to  pustules  which  finally,  as  desiccation  proceeds, 
form  crusts;  that  the  lesions  are  not  met  with  on  the  palms  of  the 
hands  or  soles  of  the  feet;  or  that  the  pocks  collapse  on  puncturing 
with  a  needle;  and  finally  that  the  whole  process  of  development  may 
occupy  less  than  a  week.  These  exceptional  conditions  prove  extremely 
confusing,  if  we  expect  to  find  in  all  cases  the  regular  order  of  symp- 
toms as  detailed  under  a  typical  case  of  variola  vera.  Yet  all  these  ex- 
ceptions may  be  encountered  and  still  the  case  be  one  of  small-pox. 

How,  then,  are  we  to  recognize  the  disease  and  differentiate  it  from 
other  affections  to  which  it  bears  a  striking  resemblance?  After  an 
extensive  study  of  the  affection  covering  a  period  of  eighteen  years, 
and  embracing  numerous  epidemics  in  different  countries  where  cli- 
matic conditions  are  greatly  at  variance,  the  writer  has  formulated  the 
definition  of  varioloid,  previously  given,  as  the  disease  of  exceptions. 
During  the  early  part  of  an  epidemic,  or  in  sporadic  cases,  there  are 
few  physicians  who  may  not  be  thrown  off  their  guard  and  fail  to  recog- 
nize a  mild  form  of  variola.  Especially  is  this  the  case  when  mild  initial 
symptoms  are  followed  by  an  eruptive  stage  in  which  but  two  or  three 
lesions  are  present,  as  we  have  repeatedly  observed  at  the  Small-pox 
Hospital;  or,  when  the  eruption,  likewise  following  the  mild  initial 
stage,  goes  through  the  various  stages  of  development  in  quick  suc- 
cession, the  whole  process  being  completed  within  ten  days  or  a  fort- 
night. A  case  illustrating  this  point  may  be  given  in  brief:  During  the 
early  part  of  the  epidemic  of  1898-99  a  young  woman  presented  her- 
self with  an  eruption  which  gave  rise  to  a  wide  difference  of  opinion. 
It  was  of  a  mild  type  and  the  lesions  were  few  and  underwent  rapid 
changes  from  papules  to  vesicles,  which,  in  the  course  of  a  day  or  two, 
developed  irregularly  into  pustules.  These  varied  greatly  in  size,  the 
majority  being  no  larger  than  a  lentil.  They  were  most  prominent  on 
the  trunk,  where  their  transformation  was  the  most  rapid.  On  the 
sixth  or  seventh  day  desiccation  took  place,  and  the  crusts  dropped  off 


VARIOLA.  87 

a  few  days  later,  leaving  slightly-reddish,  pigmented  spots.  No  de- 
struction of  the  skin  took  place.  Acting  on  the  diagnosis  of  the  present 
writer,  she  was  sent  to  the  Small-pox  Hospital,  where  she  was  again  seen 
three  days  later.  At  this  time  the  rapid  changes  that  had  taken  place 
attracted  my  attention  and  led  to  further  inquiry.  It  was  ascertained 
that  a  sister,  previously  attacked,  was  suffering  with  confluent  small-pox 
in  'the  same  ward,  from  whom  fine  photographs  were  secured  from 
which  Plates  XI,  XIII,  XIV,  and  XVI  were  made.  As  neither  of  these 
patients  had  been  previously  vaccinated,  and  as  it  failed  in  the  second 
case  after  the  eruption  appeared,  it  seemed  evident  that  the  disease  was 
the  same  in  each. 

The  second  important  feature  to  bear  in  mind  is  the  character  of 
the  lesions  themselves.  The  typical  small-pox  lesion  is  indurated.  This 
feature  appears  early  in  the  development  of  the  pock,  and  is  the  last 
to  disappear.  In  anomalous  small-pox  or  varioloid  there  may  be  many 
cases  in  which  induration  cannot  be  detected.  In  fact,  the  most  promi- 
nent lesions  may  be  composed  of  small  blisters  containing  either  a  clear 
serum  or  pus,  which,  when  punctured,  completely  collapse,  leaving  no 
induration  in  the  skin,  and  if  the  shriveled  epidermic  covering  be  re- 
moved by  slight  friction  a  small  denuded  area  will  result.  This  resem- 
bles what  is  seen  in  varicella,  and  lesions  of  this  kind  cannot  be  con- 
sidered typical  of  variola.  In  all  cases  of  variola,  however,  certain 
lesions  will  be  found  to  present  the  indurated  appearance  previously 
described.  Such  lesions,  when  punctured,  do  not  readily  discharge 
their  contents,  several  punctures  being  necessary  to  evacuate  them. 
After  this  is  done  friction  will  not  cause  denudation,  but  the  pock 
remains  as  an  elevated,  ragged  lesion.  When  seen  even  after  the  crust 
has  dropped  off,  the  areas  previously  affected  in  the  active  small-pox 
process  will  be  slightly  elevated,  with  parchment-like  induration. 

The  symptoms  of  small-pox  during  the  initial  stage  often  simulate 
CEREBRAL  MENINGITIS  more  closely  than  any  other  disease.  Again, 
from  the  severe  epigastric  pains  accompanied  by  obstinate  vomiting 
INTUSSUSCEPTION  of  the  bowels  has  been  mistaken  for  variola.  Cursch- 
mann  (loc.  tit.)  relates  an  instance  in  which  a  patient  was  sent  to  the 
hospital  with  what  was  supposed  to  be  intussusception,  which  proved 
to  be  the  initial  stage  of  hasmorrhagic  small-pox,  which  proceeded  rap- 
idly to  a  fatal  termination.  Eecently  a  case  came  under  the  author's 
observation  which  was  sent  to  the  hospital  with  severe  pain  in  the  abdo- 
men, in  which  the  diagnosis  of  APPENDICITIS  was  made  and  an  opera- 
tion performed.  Two  days  later  an  eruption  of  small-pox  broke  out. 


88  THE   ACUTE   EXANTHEMATA. 

This  is  not  given  as  an  instance  of  mistaken  diagnosis,  for  a  gangrenous 
appendix  was  found  and  the  history  of  previous  attacks  led  to  its  early 
recognition.  At  the  same  time  it  must  be  acknowledged  that  it  is  diffi- 
cult to  say  how  much  of  the  disturbance  complained  of  was  due  to  the 
gangrenous  appendix.  The  case  is  of  importance,  however,  as  it  teaches 
the  possibility  of  error,  which,  in  such  cases,  one  should  ever  bear  in 
mind.  At  other  times,  from  the  severe  gastric  disturbances  during  the 
stage  of  invasion,  the  INGESTION  of  TOXIC  SUBSTANCES  has  been  sus- 
pected. Another  instance  of  mistaken  diagnosis  resulted  more  seri- 
ously. A  patient  applied  for  admission  to  a  hospital,  and  after  being 
examined  by  the  resident  physician  was  admitted  into  the  general  ward 
with  what  was  supposed  to  be  TYPHOID  FEVER,  with  the  Widal  reaction 
well  marked.  A  few  days  later  an  eruption  appeared  which  was  at- 
tributed to  the  potassium  iodide  which  the  patient  had  taken  (20  grains 
in  the  course  of  three  or  four  days)  for  a  slight  bronchitis  likewise 
present.  It  was  not  considered  of  sufficient  importance  on  the  part  of 
the  resident  medical  officer  in  charge  to  call  special  attention  to  it  until 
six  days  after  admission,  when,  on  examination,  the  patient  presented 
a  typical  eruption  of  small-pox  in  the  pustular  stage.  The  result  may 
be  imagined;  fortunately,  however,  only  two  nurses  and  one  patient 
occupying  the  next  bed  contracted  the  disease. 

The  erythematous  rashes  which  so  frequently  accompany  the  first 
symptoms  of  variola  have  led  to  the  belief  that  one  had  to  do  with  a 
mixed  infection,  which  most  authorities  regard  as  extremely  rare.  We 
will  now  consider  seriatim  the  various  affections  with  which  small-pox 
is  most  likely  to  be  confounded. 

Measles. — A  possibility  of  error  between  measles  and  small-pox  can 
occur  only  during  the  initial  stage  and  the  beginning  of  the  stage  of 
eruption.  With  the  initial  fever  of  small-pox  it  has  been  shown  that 
an  erythematous  eruption  is  not  infrequently  observed.  When  widely 
diffused  and  blotchy,  it  may  be  mistaken  for  measles,  to  which  it  often 
bears  a  close  resemblance.  In  measles,  however,  the  rash  appears  later, 
usually  during  the  third  or  fourth  day,  and  first  shows  itself  as  reddish 
macules  on  the  face  and  upper  part  of  the  trunk,  while  these  parts  are 
the  last  to  be  involved  in  the  prodromal  rash  of  variola.  Furthermore, 
the  catarrhal  symptoms  which  are  so  prominent  in  measles  are  absent, 
or  nearly  so,  in  small-pox.  On  the  other  hand,  severe  lumbar  pains  are 
seldom  encountered  in  measles.  There  is  less  likelihood  of  error  during 
the  eruptive  stage.  In  the  confluent  and  more  especially  the  hsemor- 
rhagic  form  of  variola,  however,  mistakes  have  been  made.  It  should 


VARIOLA.  89 

be  borne  in  mind  tbat  the  lesions  in  measles  are  flat,  soft,  and  velvety 
to  the  touch,  and  when  put  on  the  stretch  shoAV  no  perceptible  thicken- 
ing of  the  skin,  while  the  early  papules  of  small-pox  are  indurated, 
small,  and  feel  like  duckshot  imbedded  in  the  skin.  In  measles  the 
blotches  develop  by  peripheral  extension  until  they  spread  out  to  dime- 
sized  areas,  while  in  small-pox  the  process  of  development  is,  though 
deeper,  more  circumscribed  and  seldom  exceeds  a  split-pea  in  size. 
Vomiting  is  not  an  infrequent  symptom  in  both  diseases,  although  it 
is  more  constant  in  variola.  In  both  diseases  blotches  may  be  detected 
in  the  fauces,  although  in  measles  the  eruption  is  more  distinctive,  as 
will  be  shown,  and  appears  fully  twenty-four  hours  before  the  skin 
shows  signs  of  implication.  This,  with  the  association  of  catarrhal 
symptoms,  will  enable  tine  to  determine  the  nature  of  the  disease.  With 
the  appearance  of  the  eruptive  stage  the  temperature  rapidly  falls  in 
variola,  while  no  remission  is  observed  in  measles.  The  prevalence  of 
an  epidemic  or  of  other  cases  in  the  immediate  vicinity  will  sometimes 
facilitate  in  making  a  diagnosis,  or  at  least  put  one  on  guard. 

Scarlet  Fever. — The  prodromal  rash  of  variola  which  counterfeits 
scarlatina  is  met  with  for  the  most  part  in  mild  cases,  and  is  accom- 
panied by  little,  if  any,  anginal  symptoms.  The  premonitory  symptoms 
are  always  severe  in  variola  and  of  two  or  three  days'  duration,  while 
in  scarlet  fever,  on  the  contrary,  they  are  of  short  duration,  usually  but 
a  few  hours,  often  slight  and  may  be  entirely  overlooked.  The  pulse 
in  the  latter  disease  is  rapid  and  out  of  proportion  to  the  fever,  while 
in  variola  the  fever  and  pulse  lines  run  nearly  parallel.  In  scarlet  fever 
the  erythematous  blush  appears  first  on  the  upper  part  of  the  chest, 
cheeks,  or  neck.  In  variola  the  scarlatiniform  rash  is  best  marked  on  the 
lower  part  of  the  abdomen  and  inner  surface  of  the  thighs.  On  careful 
examination  one  may  often  distinguish  between  the  two  diseases  from 
the  rash  alone.  It  is  bright  and  fiery  in  scarlet  fever  and  of  a  dull  red 
in  variola.  Another  distinguishing  feature  is  the  swelling  of  the  lym- 
phatic glands  about  the  lower  jaw,  so  common  in  scarlet  fever  and  sel- 
dom, if  ever,  seen  in  an  early  stage  of  variola.  The  conspicuous  papillas, 
or  strawberry  tongue,  so  constant  in  scarlet  fever,  is  also  absent  in 
variola.  Finally  the  age  of  the  patient  is  often  of  assistance.  It  should 
be  borne  in  mind  that  the  prodromal  rashes  of  variola  seldom  occur  in 
young  children,  while  adults  seldom  suffer  from  scarlet  fever. 

Impetigo. — The  differential  diagnosis  between  small-pox  and  im- 
petigo is  sometimes  a  matter  of  some  difficulty.  In  this  connection  it  is 
of  interest  to  note  that  the  prevalence  of  supposed  impetigo  in  several 


90  THE    ACUTE    EXANTHEMATA. 

towns  in  Ohio,  during  the  autumn  of  1898,  gave  rise  to  an  undoubted 
epidemic  of  small-pox.  During  the  past  year,  while  making  a  series  of 
observations  on  impetigo  and  its  various  forms,  especially  the  bullous 
impetigo,  or  the  pemphigus  contagiosus,  the  subject  of  the  differential 
diagnosis  between  small-pox  and  impetigo  was  again  brought  forcibly 
to  mind.  An  interesting  experience  in  this  connection  was  related  me 
by  a  colleague  as  follows:  The  case  in  question  occurred  on  board  the 
Yale  on  its  way  to  Santiago,  and  upon  the  diagnosis  depended  the  move- 
ment of  the  American  forces  during  the  late  Spanish-American  War. 
The  patient  causing  the  commotion  among  the  army  and  navy  medical 
authorities  was  a  native  of  Connecticut  who  had  been  previously  vac- 
cinated, and  to  the  best  of  his  knowledge  he  had  not  been  exposed  to 
small-pox.  Soon  after  embarking  he  was  attacked  with  a  bullous  erup- 
tion, which  extended  over  the  entire  body.  It  appeared  without  pre- 
monitory symptoms  of  any  kind,  and  its  presence  did  not  affect  the 
robust  health  of  the  patient.  The  bulla?  developed  until  they  attained 
a  size  varying  from  a  pea  to  a  pigeon's  egg  and  ruptured  easily,  leaving 
excoriated  surfaces  and  a  desquamative  debris  of  epidermis.  The  case 
was  pronounced  by  the  ship's  surgeon  to  be  one  of  small-pox.  The 
weight  of  this  diagnosis  was  enhanced  by  the  fact  that  the  surgeon  had 
had  much  experience  with  small-pox,  having  observed  it  in  various 
climes.  A  staff  surgeon  on  board,  who  had  charge  of  the  brigade,  was 
asked  to  see  the  case,  and  took  occasion  to  differ  from  the  opinion  ex- 
pressed, regarding  it  as  a  case  of  pemphigus.  The  patient,  however, 
was  suspended  aloft,  and  an  electric  fan-device  was  placed  under  his  cot 
to  drive  the  contagium  away  from  the  other  passengers.  Arriving  at 
Santiago  the  case  was  seen  by  the  staff  surgeon  of  the  commanding 
general,  who  confirmed  the  diagnosis  last  named.  The  man  was  sent 
ashore,  but  the  fort  medical  officer  refused  to  admit  him  on  the  ground 
that  it  was  a  case  of  small-pox.  At  this  time  it  is  said  some  friction 
arose  between  the  naval  and  land  forces  as  to  whether  the  fleet  should 
be  sent  to  harass  the  coast  of  Spain  or  continue  their  united  efforts  in 
Cuban  waters.  It  was  urged  by  the  naval  commander  that  the  case, 
being  one  of  small-pox,  the  Yah  and  its  passengers  would  have  to  un- 
dergo the  restrictions  of  quarantine;  hence  it  would  be  impossible  to 
follow  out  the  plan  proposed.  Happily,  the  recovery  of  the  patient  re- 
lieved the  difficulty,  and  thus  was  averted  a  mistake  which  might  have 
changed  the  history  of  the  war. 

During  a  recent  epidemic  the  present  writer  took  occasion  to  study 
the  various  conditions  bearing  upon  its  differential  diagnosis  from  im- 


VARIOLA.  91 

petigo,  and  in  two  instances  found  the  similarity  most  striking.  The 
first  occurred  during  the  early  stage  of  the  disease,  with  few  lesions 
present.  The  second,  of  which  an  admirable  photograph  was  obtained 
(Plate  VII),  illustrates  the  tendency  late  in  the  course  of  variola  to  as- 
sume a  bullous  character.  This  is  best  marked  on  the  hands,  and  to  a 
less  extent  on  the  feet.  It  usually  occurs  about  the  twelfth  or  fifteenth 
day  of  the  disease,  and  is  due  to  secondary  infection  by  the  ordinary  pus- 
cocci,  giving  rise  to  a  collection  of  serum  under  the  epidermis  surround- 
ing the  incrusted  small-pox  lesions.  An  intimate  familiarity  with  the 
lesions  in  both  diseases,  however,  would  readily  enable  one  to  recognize 
either  affection. 

Chicken-pox. — Unquestionably  many  errors  occur  in  determining 
between  varicella  and  variola.  In  fact,  in  Germany,  following  the 
teachings  of  Hebra,  maintained  by  Kaposi,  the  two  diseases  are  looked 
upon  by  some  as  identical,  while  in  England,  France,  and  America  they 
are  regarded  as  entirely  separate  affections.  The  subject  has  been  so 
ably  discussed  by  others  that  I  will  not  take  time  in  pursuing  it  further, 
for  it  has  been  clearly  demonstrated  that  the  two  diseases  have  nothing 
in  common,  save  the  somewhat  similar  appearance  of  the  eruptions. 

Mild  cases  of  variola,  it  is  true,  closely  simulate  varicella,  and  even 
the  experienced  diagnostician  may,  for  a  time,  hesitate  between  them. 
Investigations,  previously  detailed,  have  demonstrated  that  the  lesions 
differ  both  in  histological  location  and  in  the  manner  of  their  forma- 
tion. Thus,  the  first  changes  in  variola  take  place  deeply  in  the  stratum 
mucosum,  while  in  varicella  the  superficial  strata  of  the  epidermis  are 
principally  involved,  and  a  serous  exudate,  which  is  frequently  the  first 
symptom  of  the  disease,  occurs  at  this  point,  resulting  in  a  transparent, 
thin-walled  vesicle;  while  in  variola  the  shot-like,  deep-seated  indura- 
tion and  subsequent  vesicular  formation  are  sufficiently  distinctive  to 
warrant  a  differential  diagnosis.  The  lesions  in  varicella,  as  a  conse- 
quence, are  easily  destroyed,  and,  when  seen,  present  a  transparent, 
beady  appearance,  some  of  which,  having  ruptured,  leave  excoriated 
areas;  whereas  in  variola  it  is  impossible  to  rupture  the  lesions  so  as 
to  evacuate  the  entire  contents  without  numerous  punctures  or  by 
totally  destroying  the  diseased  area.  But  we  must  not  lose  sight  of 
the  fact  that  in  varioloid  many  lesions  may  abort,  producing  a  mixed 
eruption,  in  which  vesicles  indistinguishable  from  those  of  varicella 
may  appear,  and  that  the  presence  of  pus-cocci  often  further  masks 
their  true  nature.  Again,  as  a  rule,  variola  presents  more  uniformity  of 
development,  papules,  succeeded  by  a  whitened  appearance,  giving  rise 


92  THE   ACUTE    EXANTHEMATA. 

to  pustules,  followed  by  desiccation,  forming  blackish  crusts.  In  vari- 
cella, on  the  contrary,  multiform  lesions  are  the  rule,  macules,  vesicles, 
and  pustules,  together  with  excoriated  areas,  being  observed  at  the 
same  time.  This  is  due  to  successive  crops  of  maculae  on  the  same 
region  of  the  body,  which  are  not  observed  to  the  same  extent  in 
variola.  In  the  latter  disease  the  eruption  appears  on  the  face,  where 
it  is  usually  most  thickly  distributed,  while  in  varicella  the  trunk  is 
usually  first  attacked  and  the  parts  covered  by  the  clothing  afford  the 
usual  seat  of  predilection.  The  duration  and  development  of  the 
lesions  are  likewise  of  importance.  In  varicella  they  are  short-lived, 
an  individual  lesion  seldom  lasting  more  than  a  day  or  two;  whereas 
in  variola  they  go  through  a  regular  process  of  development  and,  ex- 
cepting in  abortive  pocks,  attain  their  maturity  about  the  eighth  day, 
after  which  desiccation  and  the  formation  of  crusts  follow.  Usually  a 
fortnight  to  three  weeks  completes  the  life-history  of  the  lesions.  In 
mild  cases  of  variola,  sometimes  called  spurious  small-pox  or  vario- 
loid,  the  time  of  development  is  shortened,  and  in  these  cases  the 
greatest  difficulty  in  diagnosis  arises,  But  even  here  the  multiform 
character  is  less  conspicuous,  as  well  as  the  successive  crops  of  the 
eruption,  and  although  the  lesions  may  only  last  a  week  or  even  less, 
there  will  be  found  some  which  adhere  to  the  type,  and  which,  with 
close  observation,  may  be  recognized  with  certainty. 

When  called  to  a  doubtful  case,  the  following  points  should  be 
carefully  considered:  The  length  of  time  since  vaccination,  and 
whether  or  not  the  patient  has  ever  had  chicken-pox.  Small-pox  is 
extremely  seldom  encountered  within  three  or  four  years  after  vac- 
cination, while  after  that  time  the  number  of  cases  of  varioloid  or 
abortive  small-pox  steadily  increases.  Chicken-pox,  like  small-pox, 
occurs  but  once  in  the  same  individual.  Prodromal  symptoms  are  al- 
ways present  for  several  days,  usually  three,  in  variola;  absent  or  of 
a  few  hours'  duration  in  varicella. 

The  temperature  often  renders  valuable  aid  in  differentiating  be- 
tween the  two  diseases.  In  variola  it  rises  rapidly,  and  even  in  mild 
or  abortive  cases  usually  reaches  103°  to  104°  F.  (39.4°-40.0°  C.), 
when,  on  the  appearance  of  the  rash,  a  crisis  takes  place,  and  it  falls 
to  the  normal  within  a  few  hours,  where  it  may  remain  throughout 
the  remainder  of  the  disease.  Varicella,  on  the  contrary,  is  seldom 
ushered  in  with  fever,  but  the  temperature  usually  rises  one  or  more 
degrees  as  the  eruption  develops.  When  the  case  is  seen  for  the  first 
time  after  the  eruption  has  appeared,  and,  as  often  occurs,  no  definite 


VARIOLA.  93 

history  can  be  obtained,  other  symptoms  must  be  relied  upon.  The 
distribution  of  the  eruption  is  usually  of  great  diagnostic  importance. 
In  varicella  the  parts  protected  by  the  clothing,  especially  the  back 
and  chest,  are  mainly  involved,  while  variola  finds  its  special  seat  of 
predilection  on  the  exposed  parts,  the  face  and  hands,  with  a  strong 
tendency  to  cluster  about  the  nose  and  forehead.  In  varicella  the  le- 
sions first  appear  as  macules,  never  indurated  as  in  small-pox,  and 
in  a  few  hours  develop  into  prominent,  transparent  vesicles  (see  Plate 
XXVI).  Umbilication  is  usually  present  at  some  period  in  the  develop- 
ment of  the  small-pox  lesion,  while  it  is  absent  in  varicella,  the  nearest 
approach  to  umbilication  being  the  formation  of  a  minute  central  crust 
as  resolution  sets  in.  As  a  rule,  the  lesions  are  of  more  uniform  size 
in  variola  than  in  varicella,  although  this  is  by  no  means  an  infallible 
test.  Until  all  doubt  as  to  the  diagnosis  is  removed,  public  safety  de- 
mands that  the  worst  be  prepared  for,  consequently  all  cases  should 
be  treated  as  small-pox  until  it  is  definitely  determined  to  the  contrary. 

Finally,  the  age  of  the  patient  is  important;  the  writer  has  never 
encountered  chicken-pox  after  puberty,  and  the  consensus  of  opinion 
bears  out  the  statement  that  it  is  essentially  a  disease  of  childhood. 

Influenza.  —  During  the  presence  of  influenza,  such  as  has  oc- 
curred in  various  countries  during  the  past  few  winters,  most  patients 
and  not  a  few  physicians  frequently  mistake  the  premonitory  symp- 
toms of  small-pox  for  "an  attack  of  la  grippe."  When  in  due  time  an 
eruption  appears,  they,  like  the  ancient  Greeks,  do  not  consider  the 
exanthem  of  sufficient  importance  to  determine  the  name  of  the  in- 
fection; hence  the  neglect,  in  many  instances,  of  the  proper  measures 
for  limiting  the  spread  of  the  disease.  Reiteration  is  not  necessary, 
for  a  careful  consideration  of  the  symptoms  will  remove  any  doubt 
that  may  at  first  exist.  The  importance  of  making  daily  visits  in  all 
suspected  cases,  especially  during  a  small-pox  epidemic,  cannot  be  too 
strongly  urged. 

Syphilis. — The  first  patient  sent  to  the  Cleveland  Small-pox  Hos- 
pital after  its  completion  was  a  negro  suffering  from  syphilis.  The 
appearance  of  eruptions  both  on  the  palms  and  soles  often  so  promi- 
nent in  small-pox  as  well  as  syphilis,  sometimes  renders  their  differ- 
entiation difficult.  Adding  to  this  the  lesions  on  the  mucous  surfaces 
that  occur  in  both  diseases,  the  clinical  picture  may  be  doubly  con- 
fusing. I  recall  a  patient  who  once  presented  himself  at  the  Mid- 
dlesex Hospital,  under  Dr.  Liveing,  in  whose  case  experienced  men 
differed  in  opinion  between  these  diseases.  A  careful  study  of  the  case, 


94  THE   ACUTE    EXANTHEMATA. 

however,  will  enable  one  to  form  a  correct  opinion  as  to  its  nature. 
The  eruption  on  the  palms  and  soles  is  always  of  diagnostic  value,  for, 
while  it  occurs  in  varicella  to  a  very  limited  extent  and  is  also  present 
in  syphilis,  it  never  assumes  the  pustular  character  so  prominent  in 
the  variolous  eruption.  That  there  is  a  distinguishing  odor  to  variola 
I  have  never  been  able  to  confirm;  an  equally  extensive  suppuration 
of  the  skin  from  other  causes,  with  like  inattention  to  cleanliness,  will, 
according  to  my  observation,  give  rise  to  the  same  nauseating  stench. 

Drug  Eruptions. — Not  infrequently,  during  the  prevalence  of 
small-pox,  suspected  cases  are  observed  at  my  clinic  manifesting  erup- 
tions which,  on  further  investigation,  prove  to  have  been  caused  by 
the  ingestion  of  cubebs  or  copaiba.  Potassium  iodide  also  sometimes 
gives  rise  to  a  pustular  eruption  which  at  first  sight  may  closely  re- 
semble that  observed  during  the  eruptive  stage  of  variola.  In  these 
cases  an  accurate  history  of  the  previous  condition  is  important.  The 
absence  of  all  febrile  symptoms  and  the  odor  of  the  drug,  which  may 
frequently  be  detected,  will  usually  enable  one  to  arrive  at  a  correct 
conclusion  as  to  their  nature. 

Eczema. — It  is  only  when  called  late  in  the  course  of  the  disease 
that  the  eruption  of  small-pox  presents  any  resemblance  to  eczema. 
Such,  however,  has  occurred  (see  Plate  XXII).  The  family  medical  at- 
tendant, seeing  the  pustular  mask  on  the  face,  regarded  it  as  a  severe 
case  of  pustular  eczema.  Close  inspection  on  the  other  parts  of  the 
body  would  have  removed  any  confusion  that  might  have  at  first  oc- 
curred. 

Finally,  in  the  differential  diagnosis  of  small-pox  the  following 
points  should  be  kept  in  mind:  First,  one  should  consider  the  possible 
sources  of  infection.  This  may  not  be  easily  discovered  in  isolated  or 
sporadic  cases,  nor  at  the  beginning  of  an  epidemic.  Second,  in  the 
eruptive  fevers,  whether  or  not  the  patient  has  previously  had  the  one 
to  which  the  symptoms  most  strongly  point.  This,  however,  should 
not  be  too  strongly  relied  upon,  especially  in  measles  and  scarlet  fever, 
although  with  them  one  attack  is  commonly  known  to  confer  more  or 
less  immunity  to  subsequent  invasion.  Third,  the  disease  is  most 
liable  to  be  variola,  when  the  most  prominent  symptoms  are:  sudden 
onset  of  chills  or  rigors,  severe  headache,  backache,  and  vomiting,  ac- 
companied by  a  rapid  rise  of  temperature,  with  delirium,  constipation 
in  adults  and  diarrhoea  in  children.  Finally,  with  the  supervention  of 
sweating,  furred  tongue,  foetid  breath,  and  the  appearance  of  an  ir- 
regular erythcmatous  or  petechial  rash,  first  appearing  and  best  marked 


VARIOLA.  95 

on  the  crural  triangle  of  Simon,  little  doubt  may  usually  be  entertained 
as  to  the  nature  of  the  affection. 

PROGNOSIS. 

-In  prevaccination  days  small-pox  was  the  greatest  scourge  that 
has  ever  afflicted  the  human  race,  and  now,  in  countries  where  vac- 
cination is  not  performed,  the  death-rate  from  this  disease  is  extremely 
high.  Thus,  in  Donarnenez,  a  small  city  in  Finistere  containing  about 
10,000  inhabitants,  where  vaccination  had  been  singularly  neglected, 
an  epidemic  of  small-pox  broke  out  in  1887  and  1888,  in  which  1931 
persons,  nearly  one-fifth  of  the  entire  population,133  perished.  The 
prevalence  of  small-pox  in  Germany  may  be  inferred  from  a  quaint  old 
saying:  Von  Pocken  und  Liebe  bleiben  wenig  Mensclien  frei.13*  Accord- 
ing to  Neve,135  fully  75  per  cent,  of  the  entire  population  of  Cashmere 
die  in  infancy  from  small-pox.  Since  the  investigations  of  Jenner  in 
1799,  in  which  vaccination  received  scientific  recognition,  small-pox 
has  lost  its  appalling  fatality,  and  is  now  known  to  be  amenable  to 
perfect  control.  Unfortunately  ignorance  and  the  prejudices  arising 
therefrom  render  protective  measures  to  a  certain  degree  ineffective. 
In  the  prognosis  of  small-pox  we  must  consider  at  the  outset  whether 
or  not  the  patient  has  been  vaccinated  and  the  time  since  the  last 
successful  vaccination.  In  Great  Britain  two  of  the  strongest  advo- 
cates for  thorough  vaccination  are  MacCombie  and  J.  W.  Moore,  both 
having  had  largely  to  do  with  small-pox  epidemics  covering  many  years 
in  institutions  in  which  accurate  statistics  have  been  compiled.  I  shall, 
therefore,  take  some  liberty  in  quoting  from  their  masterly  contribu- 
tions on  this  subject. 

The  general  fatality  of  small-pox  among  those  who  have  never 
been  vaccinated  is  greatest  in  children  between  one  and  ten  years  of 
age,  not  infrequently  reaching  as  high  as  58  per  cent.  Thus,  during 
the  Sheffield  epidemic,  of  2892  unvaccinated  children  under  ten  years 
of  age  living  in  infected  houses,  7.8  per  cent,  were  attacked,  while  dur- 
ing the  Warrington  epidemic  54.5  per  cent,  of  unvaccinated  children 
under  ten  years  of  age  living  in  infected  houses  were  attacked.  Not 
only  is  the  resistance  less  at  this  period,  but  in  infants  at  the  breast 
the  implication  of  the  mouth,  nose,  and  pharynx  often  seriously  inter- 

133  Brouardel  (P.):  "Vaccinia,"  in  "Twentieth  Century  Practice  of  Medicine,"  vol. 
xiii,  p.  501. 

is*  "From  small-pox  and  love  few  escape." 
186  Neve  (A.):  The  Lancet,  1887,  ii,  p.  609. 


96 


THE    ACUTE    EXANTHEMATA. 


feres  with  proper  nursing,  thus  determining  the  fatal  issue.  (Plate 
XX.)  Before  Jenner's  discovery  it  is  estimated  that  one-tenth  of  all 
the  children  born  died  of  small-pox.  Again,  of  the  entire  mortality 
occurring  at  all  ages,  it  has  been  variously  estimated  that  between  7 
and  12  per  cent,  was  due  to  variola.  Between  the  ages  of  fifteen  and 
twenty  the  fewest  deaths  occur.  After  the  fortieth  year  and  as  old 
age  approaches  the  fatality  of  small-pox  is  again  high. 

TABLE    SHOWING    NUMBER    OF    CASES,    DEATHS,  AND    PERCENTAGE    OF 

MORTALITY  IN  DIFFERENT  QUINQUENNIADS  UP  TO  THIRTY. 

(Taken  from  MacCombie,  in  Allbutt's  "System.") 


UNVACCINATED. 

VACCINATED. 

Cases. 

Deaths. 

Mortality. 
Per  Cent. 

Cases. 

Deaths. 

Mortality, 
Per  Cent. 

Under  5  years  .   .    . 

1131 

647 

57.2 

385 

30 

7.8 

5  to  9  years  .... 

952 

385 

40.4 

1,468 

59 

4.0 

10  to  14  vears  .                   607 

155 

25.5 

3,080 

90 

2.9 

15  to  19  years  . 

385 

158 

41.0 

4,091 

191 

4.6 

20  to  24  years  . 

276 

128 

46.3 

3,486 

321 

9.2 

25  to  29  years  . 

199 

91 

45.7 

2,079 

228 

10.9 

30  and  upward   .    . 

390 

194 

50.0 

3,167 

522 

16.4 

Totals 

3940 

1758 

44.6 

17,756 

1441 

8.1 

In  general  the  prognosis  is  worse  in  women  than  in  men  on  ac- 
count of  the  complications  of  child-birth  and  the  conditions  which 
favor  the  haemorrhagic  variety  of  the  disease.  On  the  other  hand, 
irregular  habits  and  the  excessive  use  of  alcohol  render  the  death-rate 
among  men  likewise  very  high.  Among  prostitutes  and  dissolute  per- 
sons of  both  sexes  the  prognosis  of  small-pox  is  always  exceedingly 
grave.  The  same  holds  true  of  badly  nourished  and  overworked  per- 
sons who  are  confined  to  dark,  ill-ventilated  rooms,  or  those  convales- 
cing from  febrile  or  other  diseases.  Again,  those  who  are  enfeebled 
by  scrofula,  tuberculosis,  or  syphilis  are  likewise  prone  to  succumb 
when  attacked  with  small-pox.  It,  therefore,  follows  that  the  pre- 
vious condition  influences  to  a  high  degree  the  course  and  fatality  of 
the  disease.  Thus,  in  drunkards  and  people  who  have  lived  irregu- 
larly or  eaten  to  excess,  both  the  hsemorrhagic  and  confluent  forms  are 
common. 

The  death-rate  is  usually  higher  at  the  commencement  of  an  epi- 
demic than  at  its  close,  because  those  most  susceptible  or  wholly  un- 
protected are  usually  first  attacked. 


VARIOLA.  97 

Furthermore,  the  period  of  greatest  frequency  in  those  who  have 
been  vaccinated  occurs  in  young  adults,  between  eighteen  and  thirty 
years  of  age.  This  arises  from  failure  to  revaccinate,  and,  as  the  pro- 
tective influence  wears  off  in  time,  the  subject  is  rendered  again  sus- 
ceptible. In  nearly  all  civilized  countries,  where  vaccination  is  in 
vogue,  the  disease  is  therefore  most  frequently  encountered  at  this 
time.  The  death-rate,  however,  is  low,  although  it  varies  in  different 
epidemics. 

This  is  illustrated  by  the  following  table  taken  from  the  "Report 
of  the  Royal  Commission  of  England": — 

During  the  Sheffield  epidemic  of  1887-88,  of  825  vaccinated  per- 
sons, 

35.5  per  cent,   suffered  from  the  varioloid  type. 
50.0     "         "  "        "      discrete        " 

13.0     "         "  "  "        "      coherent      " 

1.5     "         "  "        "      confluent     " 

The  variability  referred  to  is  probably  largely  dependent  on  the 
varying  degree  of  virulence  the  virus  of  variola  possesses  at  different 
times.  Moreover,  the  prevailing  epidemic  must  be  taken  into  account, 
some  epidemics  being  mild,  while  others  are  severe.  Thus,  of  the 
large  number  of  cases  occurring  in  the  epidemic  which  has  prevailed 
throughout  this  country  during  the  past  three  years,  the  mortality  has 
not  exceeded  1  or  2  per  cent.,  while  in  severe  epidemics  it  has  reached 
as  high  as  30,  40,  or  even  60  per  cent.  In  the  "Report  of  the  Munic- 
ipal Hospital  of  Philadelphia  for  1899"  W.  M.  Welch  gives  the  aver- 
age mortality  previous  to  the  epidemic  of  1894-95  as  58.38  per  cent., 
while  during  the  epidemic  of  1871-72  the  death-rate  in  unvaccinated 
cases  reached  the  appalling  figure  of  64.41  per  cent.  In  the  epidemic 
of  1894-95  the  death-rate  was  18  per  cent.  This  offers  a  strong  con- 
trast to  the  mild  form  just  experienced,  during  which  it  has  been 
difficult  to  keep  patients  within  doors.  It  has  been  no  uncommon 
sight  to  see  "pest-house  patients"  playing  games  in  the  open  air  while 
the  disease  was  still  in  the  eruptive  stage.  That  the  prevailing  type 
is  mild  there  can  be  no  question,  as  those  unvaccinated  likewise  have 
had  the  disease  in  a  mild  form.  It  has  been  the  exception,  rather  than 
the  rule,  to  find  the  eruption  assume  a  confluent  form  even  on  the  face 
and  hands. 

On  the  other  hand,  the  degree  of  resistance  it  encounters  at  dif- 
ferent times  and  in  different  organisms  must  be  taken  into  account. 
There  can  be  no  question  that  the  fatality  of  small-pox,  as  well  as  other 


98  THE    ACUTE    EXANTHEMATA. 

diseases,  is  influenced  by  the  general  surroundings,  and  varies  to  some 
extent  according  as  the  hygienic  condition  of  the  locality  is  good  or 
bad.  In  seasons  of  extreme  cold,  when  the  poor  suffer  from  various 
privations  incident  thereto,  the  death-rate  naturally  is  higher  than 
when  these  depressing  influences  are  not  present.  The  same  holds  true 
in  damp,  or  extremely  hot,  weather.  For  this  reason  the  season  of  the 
year  materially  influences  the  mortality  of  small-pox.  It  occurs  far 
more  frequently  and  is  accompanied  by  a  higher  death-rate  during  the 
winter  months  than  in  the  summer,  although  in  the  latter  it  has  been 
observed  that  during  excessive  heat  the  death-rate  is  also  high. 

From  the  foregoing  it  follows  that  races  and  communities  in 
which  general  hygienic  conditions  are  ignored  may  not  only  show  a 
greater  number  of  cases,  but  will  present  a  higher  death-rate,  than 
when  the  opposite  conditions  obtain.  In  this  way  the  high  mortality 
from  small-pox  may  be  accounted  for  in  the  slum  districts  of  large 
cities,  and  among  negroes  and  Indians. 

Of  850  cases  reported  by  Curschmann  (loc.  cit.,  p.  392),  235  suf- 
fered from  variola  vera,  and  of  these  46  were  hasmorrhagic  and  all  died. 
Altogether  there  were  99  deaths,  or  about  42.5  per  cent.  If  the  haem- 
orrhagic  cases  are  excluded,  the  mortality  of  the  other  varieties  was 
28.2  per  cent.  This,  he  remarks,  is  a  high  percentage,  and  was  due  to 
the  character  of  the  patients — hospital  cases  from  the  poorer  classes, 
An  average  percentage  can  only  be  given  approximately;  in  confluent 
small-pox  it  varies  between  15  and  30  per  cent. 

Initial  rashes  occur  usually  in  mild  cases,  and  when  the  initial  rash 
is  of  a  mild  nature  the  prognosis  is  good.  On  the  contrary,  severe  ini- 
tial rashes  do  not  necessarily  indicate  that  a  fatal  or  even  severe  disease 
will  follow.  If  a  general  erythema  occurs  with  moderate  fever  in  which 
the  temperature  does  not  exceed  100°  F.  (37.7°  C.),  and  especially  if  the 
rash  assumes  a  dark,  dusky,  or  vivid  color  and  is  most  marked  in  the 
abdomino-crural  and  axillary  triangles,  the  case  will  probably  be  haem- 
orrhagic  and  therefore  fatal.  Partial  erythemas  or  those  occurring  over 
small  areas,  of  a  pinkish  color  and  unaccompanied  by  hasmorrhagic 
signs,  are  usually  followed  by  mild  attacks;  but,  if  purple  petechiae 
in  the  groins  or  elsewhere  accompany  the  general  rash,  the  case  will 
probably  prove  fatal,  and,  if  accompanied  by  isolated  dark  spots  re- 
sembling ink-stains,  a  fatal  termination  may  be  assuredly  expected.  In 
general,  the  prognosis  as  presaged  by  the  initial  rash,  depends  upon 
the  depth  of  color  the  eruption  assumes;  thus,  a  dusky  purple  or  black- 
ish tint  foretells  hsemorrhagic  small-pox,  and  consequently  a  fatal 


VARIOLA.  99 

issue;  while  the  light  rashes  are  followed  by  mild  attacks  and  recov- 
ery. The  same  holds  true  of  oozing  of  blood  from  the  mucous  mem- 
branes, or  haematuria  during  the  initial  stage.  Finally,  the  prognosis 
in  individual  cases  may  sometimes  be  foretold  from  the  character  of 
the  early  symptoms.  In  exceptional  cases  this  may  be  done  even  in 
the  prodromal  stage.  With  mild  constitutional  symptoms  when  the 
rash  occurs  late  on  the  fourth  or  fifth  day  the  prognosis  is  invariably 
good.  The  reverse  does  not  always  hold  true,  for  with  severe  prodro- 
mal symptoms  and  the  early  appearance  of  the  rash  the  disease  may 
likewise  prove  of  a  mild  nature.  In  the  eruptive  stage  the  number  of 
pocks  usually  determines  the  severity  of  the  disease.  In  unmodified 
small-pox  when  the  eruption  is  confluent  on  the  face,  head,  arms,  and 
back,  recovery  is  doubtful,  and  a  guarded  prognosis  should  be  given, 
while  with  a  discrete  eruption  on  the  back,  although  confluent  on  the 
exposed  parts  (face,  scalp,  and  hands)  most  patients  recover.  When 
the  haemorrhagic  variety  develops  in  the  early  eruptive  stage  the  out- 
come is  invariably  fatal,  while  in  cases  in  which  the  haemorrhagic  tend- 
ency appears,  after  the  full  development  of  the  lesions  the  prognosis, 
although  extremely  grave,  is  not  always  hopeless.  According  to  Mac- 
Combie,  the  presence  of  claret-colored  areolas  encircling  the  majority 
of  the  vesicles  early  in  the  course  of  the  eruption  (second  or  third  day) 
is  a  most  unfavorable  sign,  and  affords  early  evidence  of  the  probably 
fatal  termination  of  the  disease.  Again,  haemorrhages  occurring  on  the 
lower  extremities  alone,  due  to  their  dependent  position,  do  not  neces- 
sarily indicate  a  severe  or  fatal  form  of  the  disease.  Such  patients  often 
recover,  although,  as  previously  stated,  convalescence  is  usually  re- 
tarded. 

Varioloid  is  seldom  fatal,  and,  when  death  occurs,  it  is  the  result 
of  complications,  as  in  those  debilitated  by  old  age  or  some  previous 
disease;  while  confluent  small-pox  is  extremely  dangerous,  and  the 
haamorrhagic  form  the  most  fatal  of  all. 

It  is  commonly  observed  that  an  eruption  on  the  mucous  mem- 
branes influences  to  a  high  degree  the  mortality  of  small-pox,  in  child- 
hood by  interfering  with  the  obtaining  of  sufficient  nourishment,  while 
in  adults  who  possess  a  latent  tendency  to  disturbances  of  the  bronchial 
tubes,  bronchitis,  pneumonia,  and  other  affections  of  the  lungs  are  very 
liable  to  ensue.  When  tuberculosis  co-exists,  the  prognosis  is  unfavor- 
able. In  like  manner  the  mucous  membranes  of  the  alimentary  and 
genito-urinary  tracts  are  sometimes  involved,  although  usually  to  a  less 
degree,  when  the  prognosis  is  uncertain.  When  diarrhoea,  accompanied 


100  THE   ACUTE    EXANTHEMATA. 

by  restlessness  and  delirium  supervenes,  the  gravity  of  the  disease  is 
heightened.  Symptoms  of  grave  cerebral  disturbance — such  as  de- 
lirium, convulsions,  and  coma — are  always  to  be  looked  upon  as  ex- 
tremely grave. 

The  duration  of  small-pox  varies  in  different  epidemics  and  in 
individual  cases.  Varioloid  often  terminates  within  ten  days  or  a  fort- 
night, while  severe  cases  or  variola  vera  usually  last  from  six  to  nine 
weeks.  When  complications  occur  the  disease  may  be  protracted  in- 
definitely. 

TREATMENT. 

In  the  treatment  or  management  of  small-pox  two  main  consid- 
erations present  themselves  to  the  physician:  First,  the  prevention  of 
its  spread  to  others,  and,  second,  the  actual  treatment  of  the  disease 
itself.  In  regard  to  the  first  much  may  be  done,  and  in  communities 
sufficiently  intelligent  to  heed  the  advice  of  one  skilled  in  this  depart- 
ment of  medicine,  or  in  isolated  localities  which  are  strictly  under  the 
control  of  the  health  authorities,  the  disease  may  be  held  in  complete 
control.  Under  the  second  head  it  may  be  stated  at  the  outset  that  no 
specific  treatment  can  be  given  that  will  invariably  either  cut  short  an 
attack  already  commenced  or  modify  to  any  great  extent  the  severity 
of  its  symptoms. 

Preventive  Treatment. — The  prophylaxis  of  small-pox  is  by  far  the 
most  important  consideration  at  the  outbreak  of  the  disease.  Small- 
pox being  highly  contagious  and  its  virus  retaining  its  virulence  a  long 
time,  it  is  essential  that  the  rules  governing  its  spread  and  extermina- 
tion be  well  understood. 

Quarantine. — The  first  thing  to  do  when  a  case  of  small-pox  oc- 
curs is  to  notify  the  officer  of  public  health.  Strict  quarantine  should 
be  immediately  established  and  no  one  allowed  either  to  enter  or  leave 
the  infected  dwelling.  If  possible,  especially  in  thickly  settled  com- 
munities, the  patient  should  be  removed  in  an  ambulance,  maintained 
for  the  purpose,  to  a  small-pox  hospital.  Such  a  hospital  should  be 
established  in  all  cities,  together  with  a  place  for  detaining  suspected 
patients  or  those  known  to  have  been  directly  exposed  to  the  disease. 
The  buildings  should  be  separate  and  situated  within  easy  access,  so 
that  the  dangers  incident  both  to  the  patient  and  community  during 
transportation  may  be  minimized.  In  towns  where  no  such  arrange- 
ments exist  an  isolated  building  should,  if  possible,  be  secured.  When 
this  is  found  impracticable,  a  large  room  as  far  distant  from  the  living 


VARIOLA.  101 

rooms  as  possible  should  be  selected  and  cleared  of  all  articles  not  in 
actual  use.  A  sheet  kept  constantly  saturated  with  a  3-per-cent.  solu- 
tion of  carbolic  acid,  chloride  of  lime,  or  corrosive  sublimate  (1  to 
1000)  should  be  hung  outside  the  door.  The  efficacy  of  quarantine  in 
preventing  the  diffusion  of  small-pox  may  be  illustrated  by  the  absence 
of  the  disease  in  countries  which,  from  their  geographical  position  or 
wide  separation  by  a  long  sea-voyage  from  infected  ports,  enjoy  a 
natural  isolation.  Xot  until  1838  did  the  disease  appear  in  Australia, 
and  it  is  said  that  by  observing  rigid  rules  of  quarantine  it  was  soon 
stamped  out  and  did  not  reappear  until  1868.  Further,  this  second 
invasion  soon  died  out,  and  by  the  careful  inspection  of  incoming  ships 
it  has  been  found  possible  to  prevent  subsequent  importations.136  Xew 
Zealand  has  (1891)  likewise  enjoyed  complete  immunity. 

Vaccination. — Second,  all  persons  known  to  have  been  exposed 
should  be  vaccinated.  It  seems  well-nigh  incredible  that  vaccination 
as  a  protective  means  against  small-pox  should  receive  anything  but 
an  unqualified  approval  at  this  day.  The  public,  however,  are  not 
especially  enlightened  on  the  communication  of  disease;  hence  a  tempt- 
ing field  is  offered  for  those  who  seek  notoriety  by  posing  as  opponents 
to  that  which  has  been  the  means  of  saving  millions  of  lives,  one  of 
the  greatest  boons  vouchsafed  to  the  human  race.  Thus,  books  have 
been  written  condemning  vaccination  in  the  highest  terms,  and  en- 
deavoring to  prove  by  statistics  its  futility  as  a  protective  agent.  Con- 
sequently it  becomes  necessary  in  this  connection  to  state  concisely  a 
few  imporant  facts  relative  to  the  subject  of  vaccination. 

Few  realize  the  enormous  change  which  has  taken  place  in  regard 
to  deaths  from  small-pox  since  the  introduction  of  vaccination.  In 
Europe  during  the  eighteenth  century  the  deaths  averaged  about  one- 
half  a  million  annually.  That  vaccination  prevents  small-pox  in  the 
great  majority  of  cases  no  one  who  has  had  much  to  do  with  the 
disease  doubts.  That  in  a  limited  number  of  cases  those  who  have 
been  vaccinated  afterward  contract  small-pox  does  not  militate  against 
its  value  as  a  prophylactic  measure.  Especially  is  this  true  when  such 
attacks  are  known  to  be  of  a  mild  nature  and  seldom  fatal.  That 
those,  who,  having  once  been  vaccinated,  may  subsequently  return  to 
a  susceptible  condition  after  the  lapse  of  a  certain  though  variable 
length  of  time  is  likewise  well  acknowledged.  That  in  the  process  of 
vaccination  pus  organisms  and  other  extraneous  septic  substances  are 

138  Hirsch  (August):  "Historical  and  Geographical  Pathology,"  1881,  vol.  1,  pp. 
133  and  134. 


102 


THE    ACUTE    EXANTHEMATA. 


oftentimes  introduced  through  the  carelessness  of  the  operator  and 
his  failure  to  institute  proper  precautions,  thus  causing  inflammations 
which  sometimes  result  seriously,  cannot  be  denied.  On  the  other 
hand,  and  I  believe  more  frequently,  the  utter  disregard  of  all  cleanly 
habits  on  the  part  of  the  patient  and  his  want  of  appreciation  of  the  im- 
portance of  asepsis,  accounts  for  many  of  the  complaints  raised  against 
the  practice  of  vaccination.  That  such  accidents  in  no  way  militate 
against  the  value  of  vaccination,  as  a  preventive  measure,  nor  disprove 
its  harmlessness  when  properly  performed  and  properly  cared  for,  must 
be  evident.  The  subject  of  vaccination  and  its  influence  in  reducing 
the  prevalence  of,  and  mortality  from,  small-pox  has  been  exhaustively 
studied  in  England  by  a  commission  appointed  by  the  government  for 
this  purpose.137  The  importance  attached  to  the  findings  of  this  com- 
mission will  scarcely  be  questioned  when  it  is  known  that  it  included 
such  well  known  medical  men  as  Paget,  Savory,  Bristowe,  Jonathan 
Hutchinson,  and  Michael  Foster,  together  with  a  few  public  men  of 
various  opinions.  The  commission  finally  finished  its  labors  in  1897, 
having  extended  over  a  period  of  eight  years.  Experts  were  secured 
to  study  various  epidemics  in  Great  Britain,  187  witnesses  were  exam- 
ined, and  136  meetings  were  held.  In  arriving  at  its  conclusions  the 
commission  brought  to  light  much  valuable  information  relative  to  the 
subject  of  small-pox  in  all  its  bearings. 

For  example,  carefully  compiled  statistics  as  to  the  effect  of  vac- 
cination in  five  towns  of  England  in  which  epidemics  occurred  are  given 
as  follows: — 


ATTACK-RATE  UNDER  TEN. 

ATTACK  RATE  OVER  TEN. 

Vaccinated. 

Unvaccinated. 

Vaccinated. 

Unvaccinated. 

Sheffield.              .    . 
Warringtoii   ...            .    . 

7.9 
4.4 
10.2 
2.5 

8.8 

67.6 
54.5 
50.8 
35.3 
46.3 

28.3 
29.9 
27.7 
22.2 
32.2 

53.6 
57.6 
53.4 
47.6 
50.0 

Dewsbury      .       .    . 
Leicester           .... 

Gloucester  .    .        

That  vaccination  favorably  effects  the  mortality-rate  and  the  se- 
verity of  the  disease  even  in  persons  who  contract  it  afterward  is  like- 
wise very  clearly  brought  out  by  the  report  of  the  commission.  In 


is?  "Vaccination  and  its  Results.     A  Report  based  on  the  Evidences  taken  by  the 
Royal  Commission,  1889-97."     New  Sydenham  Society  (London,  1893). 


VARIOLA.  103 

Sheffield,  for  instance,  of  4151  vaccinated  persons  attacked,  200 — or 
4.8-  per  cent. — died;  of  552  unvaccinated  persons  attacked,  274— 
or  49.6  per  cent. — died;  so  that  the  mortality  among  the  unvaccinated 
was  more  than  ten  times  greater  than  among  the  vaccinated.  Of  those 
attacked,  353  were  vaccinated  children  under  ten  years  of  age,  of 
whom  1.7  per  cent,  died;  while  of  228  unvaccinated  children  attacked, 
43.9  per  cent,  died;  so  that  among  children  the  disease  was  more  than 
twenty-five  times  as  fatal  among  the  unvaccinated  than  among  the  vac- 
cinated. Statistics  like  the  above  might  be  multiplied  almost  in- 
definitely, showing  clearly  that  under  compulsory  vaccination  the  dis- 
ease not  only  tends  to  be  changed  from  one  of  childhood  to  one  of 
adult  life,  as  has  previously  been  shown,  but  of  even  greater  moment 
that  it  is  much  less  fatal  among  those  attacked. 

Of  5321  cases  of  small-pox  at  the  Municipal  Hospital  of  Philadel- 
phia, Welch  observed  only  2  vaccinated  children  (loc.  cit.,  p.  566). 

It  has  been  found  that  the  period  immediately  following  the  in- 
troduction of  vaccination  is,  in  all  countries,  characterized  by  a  marked, 
though  irregular,  diminution  of  small-pox  mortality.  That  the  nine- 
teenth century  has  witnessed  epidemics  of  considerable  severity  even 
in  countries  where  vaccination  has  largely  prevailed  cannot  be  denied, 
but  there  has  always  been  in  those  countries  a  class,  more  or  less  nu- 
merous, of  unvaccinated  persons.  Moreover,  experience  teaches  that 
the  protective  effect  of  vaccination  diminishes  in  force,  or  may  even 
disappear  after  the  lapse  of,  say,  ten  years  from  the  date  of  operation; 
hence  there  may  be  always  found  persons  supposed  to  be  made  im- 
mune by  vaccination  but  in  whom  the  protective  influence  has  disap- 
peared, who  are  liable  to  be  attacked  and  to  suffer  more  or  less  from 
the  disease.  That  epidemics  have  from  time  to  time  occurred,  and 
that  deaths  from  small-pox  continue,  cannot,  therefore,  reasonably  be 
accepted  as  a  proof  that  small-pox  is  uninfluenced  by  vaccination. 

Duration  of  the  Immunity. — Jenner  at  first  thought  that  vaccina- 
tion insured  immunity  for  life,138  but  as  early  as  1805  it  was  observed 
that  epidemics  of  small-pox  occurred  in  communities  supposed  to  be 
protected  by  vaccination.  During  the  first  quarter  of  the  nineteenth 
century  these  epidemics  increased  in  number  and  severity,  which  led 
to  the  conclusion  that  the  protective  influence  of  vaccination  became 


138  "Vaccination,  duly  and  efficiently  performed,  will  protect  the  constitution  from 
subsequent  attacks  of  small-pox  as  much  as  that  disease  itself  will.  I  never  expected  it 
would  do  more,  and  it  will  not,  I  believe,  do  less."  Baron,  "Life  of  Jenner"  (London, 
1838),  vol.  11. 


104 


THE    ACUTE    EXANTHEMATA. 


gradually  less,  and  in  some,  at  least,  wholly  disappeared.  It  was  fur- 
ther observed  that,  in  many,  exposure  to  small-pox  resulted  in  what  was 
called  varioloid,  because  it  was  supposed  to  be  a  distinct  disease  resem- 
bling small-pox.  To  Husson  and  Bousquet139  has  been  given  the  credit 
of  advising  revaccination,  which  was  first  practiced  on  a  large  scale  in 
Prussia.  Of  great  importance  in  this  connection  is  the  effect  of  a  law 
passed  in  Prussia  in  1874  making  revaccination  compulsory.  Since 
that  period  the  small-pox  mortality  in  that  country  has  been  reduced 
to  proportions  quite  insignificant  as  compared  with  any  previous  epoch. 
It  is  likewise  instructive  to  compare  the  deaths  from  small-pox  per 
100,000  of  the  population  in  Prussia  and  Austria,  where  revaccination 
was  not  enforced.  It  may  be  said  that  prior  to  1874  the  mortality 
from  small-pox  varied  from  year  to  year,  being  sometimes  greater  in 
one  country,  sometimes  in  the  other,  but  subsequent  to  the  passage  of 
the  law  making  vaccination  compulsory  in  Prussia  the  contrast  is  re- 
markable. The  figures  for  1874  and  for  some  years  prior  and  subse- 
quent to  that  date  are  therefore  worth  placing  side  by  side: — 


PRUSSIA. 

AUSTRIA. 

PRUSSIA. 

AUSTRIA. 

Revaccination 

Revaccin  at  ion 

Revaccination 

Revaccination 

Compulsory. 

Compulsory. 

Compulsory. 

Compulsory. 

1862 

21.06 

31.14 

1872 

262.37 

189.93 

1863 

33.80 

53.10 

1873 

35.65 

323.36 

1864 

46.25 

84.78 

1874 

9.52 

178.19 

1865 

43.78 

45.53 

1875 

3.60 

57.73 

1866                 62.00 

36.85 

1876 

3.14 

39.28 

1867                 43.17 

74.08 

1877 

0.34 

53.18 

1868                  ]*>! 

33.27 

1878 

0.71 

60.59 

1869                 19.42 

35.18 

1879 

1.26 

50.83 

1870                 17.52 

30.30 

1880 

2.60 

64.31 

1871 

243.21 

39.28 

1881 

3.62 

82.67 

Further  striking  instances  of  the  effect  of  revaccination  nn'ght  be 
given.  For  instance,  the  staff  of  the  Small-pox  Hospital  at  Leicester 
in  1892  consisted  of  28  persons,  14  of  whom  had  either  previously  had 
small-pox  or  had  been  revaccinated  before  the  outbreak  of  the  epi- 
demic. Eight  others  were  vaccinated  at  the  time  of  the  outbreak. 
The  remaining  6  had  been  vaccinated  in  childhood,  but  refused  to  be 
revaccinated.  Of  the  28  persons,  6  were  attacked  by  the  disease  and 
1  died.  Five  of  those  attacked,  including  the  fatal  case,  were  among 


188  Bousquet:   "Traits  de  la  vaccine  et  des  Eruptions  varioleuses  au  varioliformes" 
(Paris,  1833). 


VAEIOLA.  105 

the  six  persons  who  had  refused  to  be  revaccinated.  The  sixth  case 
was  that  of  a  nurse  who  had  been  revaccinated  ten  years  before.  In 
the  epidemic  at  Warrington,  of  the  593  vaccinated  cases,  323,  or  54.5 
per  cent.,  were  mild;  141,  or  23.8  per  cent.,  were  discrete;  129,  or 
21.8  per  cent.,  were  confluent.  Of  the  68  unvaccinated  cases,  3,  or  4.4 
per  cent.,  were  mild;  17,  or  25  per  cent.,  were  discrete;  48,  or  70.6 
per  cent.,  were  confluent.  That  is,  of  the  vaccinated  cases  54.5  per 
cent,  were  mild  and  21.8  per  cent,  were  confluent.  Of  the  unvac- 
cinated, 4.4  per  cent/were  mild  and  70.6  per  cent,  were  confluent. 

According  to  Marson,  during  the  period  of  thirty-five  years  pre- 
ceding his  report  (1871)  no  nurse  or  servant  at  the  London  Small-pox 
Hospital  had  been  attacked  with  small-pox.  Since  then  up  to  the 
present  time  one  case  only,  that  of  a  gardener,  has  occurred;  so  that 
there  is  now  a  record  of  nearly  seventy  years  with  one  case  only.  Of 
the  137  nurses  and  attendants  employed  since  1883,  all  who  had  not 
previously  had  small-pox  were  revaccinated  upon  entering,  with  the 
exception  of  the  gardener,  who  took  the  disease.  Investigations  by  a 
committee  from  the  Epidemiological  Society  of  London  showed  that 
of  1500  attendants  and  others  connected  with  small-pox  institutions, 
only  43  were  found  to  have  contracted  the  disease,  and  not  one  of  these 
forty-three  had  ever  been  revaccinated.140  "Welch  states  that  at  the 
Municipal  Hospital  of  Philadelphia  during  a  period  of  twenty-five 
years  no  one  who  has  recently  been  vaccinated  has  contracted  small-pox 
(loc.  cit.). 

In  the  author's  experience,  no  instance  has  ever  occurred  of  a 
physician,  nurse,  or  attendant  contracting  small-pox  in  the  discharge 
of  duty  in  a  small-pox  hospital  or  pest-house  who  had  a  short  time 
previously  been  carefully  vaccinated. 

The  commission  previously  referred  to  ascertained  that,  if  hos- 
pital experience  be  regarded  as  a  whole,  there  is  clear  evidence  that, 
while  the  revaccinated  attendants  escape  small-pox,  many  of  those  who 
have  neither  passed  through  an  attack  of  small-pox  nor  been  revac- 
cinated are  attacked  by  the  disease.  Moreover,  it  cannot  be  asserted 
that  persons  employed  in  hospitals  as  medical  men  or  attendants,  even 
if  revaccinated,  enjoy  an  absolute  immunity  from  the  disease.  There 
are  instances  of  such  persons  having  been  attacked,  but  they  have  been 
so  rare  and  exceptional  as  not  to  substantially  modify  the  conclusion 
otherwise  arrived  at. 

The  conclusions  formulated  by  the  Royal  Commission  are  as  fol- 


140  "Transactions  of  the  Epidemiological  Society,"  1885,  vol.  v,  New  Series. 


106  THE   ACUTE    EXANTHEMATA. 

low:  "We  have  not  disregarded  the  arguments  adduced  for  the  pur- 
pose of  showing  that  a  belief  in  vaccination  is  unsupported  by  a  just 
view  of  the  facts.  We  have  endeavored  to  give  full  weight  to  them. 
Having  done  so,  it  has  appeared  to  us  impossible  to  resist  the  conclu- 
sion that  vaccination  has  a  protective  effect  in  relation  to  small-pox. 
We  think:— 

"1.  That  it  diminishes  the  liability  to  be  attacked  by  the  disease. 

"2.  That  it  modifies  the  character  of  the  disease,  and  renders  it 
(a)  less  fatal  and  (b)  of  a  milder  or  less  severe  type. 

"3.  That  the  protection  it  affords  against  attacks  of  the  disease  is 
greatest  during  the  years  immediately  succeeding  the  operation  of  vac- 
cination. It  is  impossible  to  fix  with  precision  the  length  of  this  period 
of  highest  protection.  Though  not  in  all  cases  the  same,  if  a  period  is 
to  be  fixed,  it  might,  we  think,  fairly  be  said  to  cover,  in  general,  a 
period  of  nine  or  ten  years. 

"4.  That,  after  the  lapse  of  the  period  of  highest  protective  po- 
tency, the  efficacy  of  vaccination  to  protect  against  attack  rapidly 
diminishes,  but  that  it  is  still  considerable  in  the  next  quinquennium, 
and  possibly  never  altogether  ceases. 

"5.  That  its  power  to  modify  the  character  of  the  disease  is  also 
greatest  in  the  period  in  which  its  power  to  protect  from  attack  is 
greatest,  but  that  its  power  thus  to  modify  the  disease  does  not  dimin- 
ish as  rapidly  as  its  protective  influence  against  attacks,  and  its  efficacy 
during  the  later  periods  of  life  to  modify  the  disease  is  still  very  con- 
siderable. 

"6.  That  revaccination  restores  the  protection  which  lapse  of  time 
has  diminished;  but  the  evidence  shows  that  this  protection  again  di- 
minishes, and  that,  to  insure  the  highest  degree  of  protection  which 
vaccination  can  give,  the  operation  should  be,  at  intervals,  repeated. 

"7.  That  the  beneficial  effects  of  vaccination  are  most  experienced 
by  those  in  whose  case  it  has  been  more  thorough.  We  think  it  may 
fairly  be  concluded  that,  where  the  vaccine  matter  is  inserted  in  three 
or  four  places,  it  is  more  effectual  than  when  introduced  into  one  or 
two  places  only;  and  that,  if  the  vaccination  marks  are  of  an  area  of 
half  a  square  inch,  they  indicate  a  better  state  of  protection  than  if 
their  area  be  at  all  considerably  below  this." 

After  viewing  the  subject  in  the  broadest  light  there  can  be  no 
doubt  that,  of  all  measures  against  the  spread  and  fatality  of  small-pox, 
vaccination  and  revaccination  occupy  the  highest  position,  and  if  thor- 
oughly carried  out  would  eventually  wholly  stamp  out  the  disease.  In 


VARIOLA. 


107 


fact,  although  it  is  a  matter  of  common  remark  that  statistics  are  mis- 
leading, I  believe  it  is  hardly  possible  for  an  unprejudiced  person  to 
go  over  statistics  with  reference  to  small-pox  which  have  not  been  col- 
lated unfairly  without  concluding  that  vaccination  is  effective,  not  in 
the  absolute  sense,  but  in  proportion  to  the  thoroughness  with  which 
it  is  carried  out;  that  recently  vaccinated  persons  in  whom  the  virus 
has  taken  in  a  thoroughly  typical  way  are  practically  insusceptible  to 
the  disease;  that  as  the  years  go  by  they  become  more  and  more  sus- 
ceptible to  it,  but  that  persons  who  have  been  once  vaccinated  are, 
even  after  many  years,  less  liable  to  the  disease  in  the  severer  form. 
These  facts  point  very  strongly  to  the  necessity  of  revaccination. 

In  answer  to  the  question,  as  to  when  revaccination  should  be  per- 
formed, the  following  statistics141  are  of  interest.  In  these  tables  S 
denotes  successful  cases,  F  denotes  failures.  Calf  lymph  prepared  with 
glycerin  was  used,  and  all  persons  who  presented  themselves  were  re- 
vaccinated.  The  lymph  was  inserted  in  four  places  on  the  arm.  Table 
A  includes  148  children  who  had  all  been  vaccinated  in  infancy.  No 
revaccinations  were  successful  in  children  under  four  years  of  age. 
Table  B  is  of  183  persons  over  twenty-four  years  of  age  who  had  been 
vaccinated  later  in  life  than  the  fourteenth  year. 

TABLE  A.    NUMBER  OF  YEARS  SINCE  LAST  VACCINATION. 


4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

S   F 

S    F 

S    F 

S    F 

S     F 

S     F 

S     F 

S     F 

S     F 

S     F 

S     F 

3 

/> 

7 

6 

15    1 

. 

14 

19 

20 

15 

16 

26 

TABLE  B.    NUMBER  OF  YEARS  SINCE  LAST  VACCINATION. 


1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

S      F 

S      F 

S      F 

S      F 

S      F 

S      F 

S      F 

S      F 

S      F 

S      F 

12 

13 

6 

8 

o 

6 

1 

1      4 

1      2 

2       2 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

OVER 
20 

S   F 

S    F 

S    F 

S    F 

S     F 

S    F 

S     F 

S    F 

S    F 

S     F 

S     F 

12 

1    2 

2    8 

3 

2     1 

2 

1 

1     2 

82    4 

It  is  interesting  to  note  that,  of  148  children  revaccinated  at  such 


141  Carter  (R.  J.):  The  Lancet,  1897,  i,  p.  1611. 


108  THE   ACUTE    EXANTHEMATA. 

varying  intervals  as  from  four  to  fourteen  years  after  the  last  vaccina- 
tion, all  except  1  were  successful.  Of  those  who  had  been  vaccinated 
after  the  age  of  fourteen  the  first  successful  case  was  eight  years  after 
the  previous  vaccination,  and  then  only  1  case  out  of  5  succeeded. 
Even  after  an  interval  of  fifteen  to  twenty  years  the  evidence  in  these 
cases  is  strong  that  some  of  them  were  still  protected.  It  is  fair  to  as- 
sume that  successful  revaccination  shows  a  previous  susceptibility  to 
small-pox  in  at  least  the  milder  form.  This  is  as  well  established  as 
any  fact  in  the  whole  range  of  science,  medical  or  otherwise.  It  is  a 
foregone  conclusion  that  any  opinion  on  this  subject  which  may  be 
arrived  at,  no  matter  how  well  borne  out  by  experience,  will  be  bit- 
terly attacked  by  a  number  of  persons,  just  as  it  is  the  fact  that  there 
is  no  theory,  however  absurd,  which  will  not  be  supported  by  some 
persons  even  of  otherwise  apparently  good  intellect. 

When  the  patient  and  those  immediately  associated  with  him  are 
seen  to,  the  community  should  receive  attention.  All  those  who  can- 
not show  recent  marks  of  vaccination  should  be  vaccinated.  It  is  often 
asked:  how  long  after  exposure  to  small-pox  may  vaccination  be  suc- 
cessfully performed.  Bryce,142  of  Edinburgh,  long  since  determined 
the  period  of  complete  immunity  by  making  fresh  inoculations  every 
day  after  the  primary  vaccination.  He  found,  while  the  effect  grew 
less  each  day,  that  pustules,  more  or  less  conforming  to  the  type,  de- 
veloped at  the  seat  of  inoculation  up  to  the  ninth  or  tenth  day,  after 
which  no  specific  reaction  could  be  obtained.  Considering  the  differ- 
ent periods  of  incubation,  it  is  generally  conceded  that  to  obtain  im- 
munity from  small-pox  not  more  than  three  or  four  days  should  elapse 
from  the  time  of  exposure  to  the  insertion  of  the  vaccine-lymph.  On 
vacating  the  apartment  occupied  by  the  small-pox  patient  and  his  im- 
mediate family,  the  rooms  should  be  thoroughly  disinfected,  and  their 
contents  either  disinfected  or  destroyed. 

Disinfection. — The  virus  of  small-pox  is  very  resistant  to  the  ordi- 
nary modes  of  disinfection,  and,  as  elsewhere  shown  (page  82),  may 
retain  its  virulence  several  years.  Where  proper  appliances  are  not  at 
hand,  or  for  other  reasons  there  is  danger  that  prophylactic  measures 
may  not  be  fully  carried  out,  the  safest  measure  is  destruction  by  fire. 
When,  however,  such  radical  measures  are  deemed  unnecessary,  the 
following  plan  may  be  adopted:  All  washable  objects,  such  as  bed- 
clothing,  curtains,  towels,  handkerchiefs,  underclothing,  etc.,  should 

"a  Bryce  (J.):  "Practical  Observations  on  the  Inoculation  of  the  Cow-pox"  (Edin- 
burgh, 1809). 


VARIOLA.  109 

be  immediately  immersed  in  a  solution  of  chlorinated  lime,  or  corrosive 
sublimate  (1  drachm  to  the  gallon  of  water),  or  they  should  be  tied 
up  in  a  clean  sheet  and  boiled  for  an  hour,  after  which  they  should  be 
taken  out  and  exposed  to  the  air  and  sun.  Mattresses,  old  clothing, 
carpets,  ornaments,  pictures,  rags,  etc.,  of  little  value,  as  well  as  all 
articles  injured  by  water  or  scrubbing,  had  better  be  burned.  The  room 
should  then  be  fumigated  by  placing  from  1  to  2  ounces  (according 
to  the  area  to  be  acted  upon)  of  corrosive  sublimate  (mercuric  chloride) 
on  a,  plate  which  is  heated  over  a  spirit-lamp  or  charcoal-fire  in  the 
centre  of  the  room.  The  windows,  doors,  and  other  apertures  are  then 
closed  for  about  four  hours,  when  they  are  opened  and  the  room  freely 
aired.  As  an  extra  precaution  and  to  neutralize  any  of  the  mercurial 
vapor  which  may  linger  about  the  room,  Konig143  advises  that  on  the 
following  day  the  room  be  again  closed  and  sulphur,  1361  grammes  to 
400  cubic  metres  of  air-space  (3  pounds  to  1000  cubic  feet),  burned  inv 
the  same  way  and  the  fumes  retained  four  hours.  Should  it  be  neces- 
sary to  enter  the  room  during  the  process  of  fumigation,  precaution 
should  be  taken  to  guard  against  inhaling  the  vapor  by  holding  a  moist 
cloth  or  sponge  over  the  mouth  and  nose.  The  room  and  its  contents 
should  then  be  thoroughly  scrubbed  with  strong  potash  soap  or  a  bi- 
chloride solution  (1  to  2000),  taking  special  care  that  all  corners  and 
cracks  are  properly  seen  to,  when  it  ma}r  be  redecorated  by  painting, 
whitewashing,  or  papering,  as  desired.  Harrington144  has  demonstrated 
the  value  of  formaldehyde  as  a  surface  disinfectant,  and  the  author's 
experience  with  it  during  the  epidemic  of  1898-1901  confirms  its  prac- 
tical application  in  the  exanthemata. 

The  preparation  of  formaldehyde  best  suited  to  surface  disinfec- 
tion is  the  aqueous  solution,  the  strength  varying  from  10  to  20  per 
cent.  For  general  interior  or  furniture  disinfection  a  solution  not 
weaker  than  15  per  cent,  should  be  used,  in  the  form  of  a  fine  spray. 
Clothing  may  be  immersed  in  a  tub  containing  the  solution,  after  which 
it  is  hung  up  until  dry.  After  spraying  the  walls,  ceiling,  floor,  all 
articles  in  the  room  are  to  be  washed  with  a  15-  or  20-per-cent.  formalin 
solution,  allowing  24  ounces  (720  grammes)  for  each  1000  cubic  feet 
(400  cubic  metres)  of  space,  and  the  doors  and  windows  closed  for  three 
or  four  days.  A  formaldehyde  spray  is  the  most  convenient  means  of 
disinfection  for  physicians  to  use  in  leaving  tthe  infected  dwelling  or 
hospital.  In  carrying  out  our  work  during  the  epidemic  mentioned, 

14S  Konig:  Vide  J.  W.  Moore,  p.  459. 

144  Harrington   (C.):  Amer.  Jour,  of  the  Med.  Sci.,  1893,  p.  56. 


110  THE   ACUTE    EXANTHEMATA. 

notwithstanding  the  exposure  resulting  from  the  use  of  a  camera  and 
the  development  of  plates  at  the  photographers,  together  with  the  ad- 
mission of  the  senior  medical  class,  no  instance  of  infection  occurred. 
On  entering  the  hospital,  hats,  gloves,  overcoats,  etc.,  were  left  in  an 
anteroom,  long  linen  gowns  were  put  on,  and  the  head  covered  with  the 
same  material.  Eubber  answers  equally  well,  and  it  is  always  advis- 
able to  wear  rubber  boots.  Before  returning  to  the  anteroom  these 
garments  were  sprayed  with  a  20-per-cent.  formalin  solution.  Upon 
entering  the  anteroom  they  were  removed  and  thrown  into  a  receptacle 
containing  the  same  solution.  The  various  articles  of  clothing  were 
then  sprayed  as  they  were  put  on,  and  the  camera,  plate-holders,  etc., 
were  subjected  to  the  same  procedure.  According  to  the  health  officer's 
report,145 150  infected  houses  were  disinfected  with  this  substance  with- 
out the  subsequent  development,  so  far  as  known,  of  a  single  case  of 
variola. 

Heat  (230°  F.,  or  110°  C.),  in  the  form  of  hot  air  or  superheated 
steam,  is  an  efficient  method  of  disinfecting  when  the  necessary  appli- 
ances are  available. 

In  the  country  or  in  the  absence  of  proper  sewer  connections,  the 
excreta  should  be  passed  into  a  vessel  and  immediately  disinfected  by 
adding  at  least  an  ounce  of  fresh  chloride  of  lime  in  solution,  or  a  pint 
of  the  corrosive-sublimate  solution,  after  which  they  should  not  be 
thrown  into  a  vault,  but  buried  at  least  100  feet  from  a  well  or  dwelling. 
When  a  water-closet  is  used  the  lime  solution  should  be  thrown  into  the 
basin  after  it  is  used  and  followed  by  thorough  flushing. 

Hygienic  Measures. — Naturally  anything  that  impairs  bodily  vigor 
lessens  the  resistance  to  disease,  small-pox  included.  Therefore  one  ex- 
posed to  variola  should  avoid  fatigue,  worry,  and  dissipation,  especially 
alcoholic  excess,  which  renders  its  habitues  not  only  more  prone  to  the 
disease,  but,  when  attacked,  assures  a  grave,  if  not  fatal,  issue.  It  is 
not  advisable  to  enter  the  sick-room  fasting  or  when  perspiring.  As  an 
additional  protective  measure,  a  moistened  cloth  or  sponge  may  be  worn 
over  the  mouth  and  nose. 

The  restrictions  imposed  upon  suspected  cases  may  be  removed  at 
the  end  of  twenty-one  days,  provided  no  symptoms  of  small-pox  appear. 

After  recovery  the  patient  should  be  given  a  momentary  bath  in 
corrosive  sublimate  (1  to  4000),  carbolic  acid  (1  to  100),  or  formalde- 
hyde (2  to  100),  which  should  be  immediately  rinsed  off  with  warm 


148  Hess  (J.  L.):  Cleveland  Jour,  of  Med.,  December,  1889. 


VAEIOLA.  Ill 

water.    He  should  then  be  supplied  with  new  or  thoroughly  disinfected 
clothing,  when  he  may  be  allowed  to  depart. 

When  death  occurs  the  body  should  be  immediately  wrapped  in  a 
wet  sheet  dipped  in  a  l-to-2000  solution  of  corrosive  sublimate;  a  20- 
per-cent.  solution  of  formaldehyde;  or  carbolic  acid,  4  ounces;  water, 
1  gallon  (120  grammes  to  water,  3840  cubic  centimetres)  (see  formulary 
at  end  of  volume).  All  clothing  used  about  the  patient  should  be 
burned.  The  body  should  be  placed  in  a  tight  receptacle  and  buried 
without  delay. 

TREATMENT  OF  THE  DISEASE. 

In  considering  the  treatment  of  small-pox  the  immediate  sur- 
roundings of  the  patient  should  receive  attention.  The  prevalent  idea, 
which  has  come  down  to  us  from  the  dark  ages,  that  those  suffering 
from  small-pox,  as  well  as  other  eruptive  fevers,  should  be  confined  in 
hot,  close  rooms,  or  covered  up  in  bed  with  heavy  blankets  to  induce 
copious  perspiration,  is  erroneous.  A  large,  cool,  well-ventilated  room, 
with  a  temperature  varying  from  65°  to  68°  F.  (18.3°  to  20.0°  C.), 
with  free  ventilation  without  allowing  draughts  of  air  to  strike  the 
patient,  should,  if  possible,  be  secured  during  the  whole  course  of  the 
disease.  It  is  highly  desirable  that  a  bath-room  adjoin  the  sick-cham- 
ber. An  open  fire-place  is  beneficial  to  secure  free  ventilation  and 
change  of  air  without  producing  draughts. 

The  body  and  bed-linen  should  be  of  the  softest  material,  and  the 
bed-coverings  should  not  only  be  soft,  but  of  light  weight.  A  hair 
mattress  on  wire  is  sufficiently  comfortable,  although,  in  some  instances 
of  confluent  small-pox,  a  water  bed  is  required.  The  bedclothing,  as 
well  as  the  furnishings  of  the  room,  should  be  of  washable  materials, 
or  of  little  value  that  they  may  be  afterward  destroyed  by  fire. 

The  importance  of  competent  nursing  cannot  be  too  strongly 
urged.  The  custom  unfortunately  in  vogue  in  many  "pest-houses," 
of  employing  an  incompetent  keeper  to  act  in  the  capacity  of  general 
manager  and  nurse,  cannot  be  too  strongly  deprecated.  Intelligent, 
trained  nurses  are  essential  in  all  well-regulated  small-pox  hospitals. 
Not  only  is  skilled  nursing  conducive  to  the  material  comfort  of  the 
patient,  but  in  many  cases  it  determines  the  issue  of  life  or  death.  A 
nurse  should  be  sufficiently  strong  to  assist  the  patient  in  changing 
his  position,  or  in  moving  him  from  place  to  place  should  occasion 
require.  Cleanliness  is  essential,  and,  as  the  discharge  is  copious,  fre- 
quent changing  of  bed-linen  and  clothing  which  comes  in  contact  with 


112  THE    ACUTE    EXANTHEMATA. 

the  patient  should  be  carefully  seen  to.  In  this  the  patient  should 
be  handled  with  the  utmost  gentleness,  the  nurse's  arms  being  placed 
under  a  pillow  upon  which  the  patient  rests,  rather  than  directly  touch- 
ing the  skin.  What  may  seem  to  be  a  slight  pressure  or  irritation  is 
oftentimes  excruciating  to  the  sufferer.  Again,  in  the  management  of 
delirious  subjects  the  utmost  care  must  be  enjoined,  lest  during  the 
nurse's  absence  the  patient  inflict  upon  himself  irreparable  injury.  Not 
infrequently  they  leap  from  open  windows,  and,  when  exasperated,  may 
inflict  upon  others  bodily  harm. 

The  question  of  light  in  the  treatment  of  small-pox  dates  back  to 
a  very  early  period,  as  we  have  previously  shown.146  John  of  Gaddesden 
advised  that  red  curtains,  red  walls,  and  red  furnishings  be  employed, 
for  in  this  color  there  was,  he  believed,  a  peculiar  virtue.  After  lying 
well-nigh  dormant  for  centuries,  the  subject  of  light  in  the  treatment 
of  small-pox  has  again  been  revived,  and  is  receiving  attention.  From 
the  fact  that  the  eruption  is  most  severe  on  parts  exposed  to  the  light, 
Black,147  of  England,  concluded,  from  analogy  as  well  as  experimenta- 
tion, that  the  complete  exclusion  of  light  in  the  management  of  small- 
pox prevents  the  severity  of  the  eruption  arid  consequent  pitting  of 
the  face.  Subsequently  Waters,148  of  London,  asserted  that  if  white 
light  (daylight)  is  entirely  excluded  from  the  patient  the  disease  will 
be  less  severe.  Likewise  Barlow,149  of  Manchester,  advocated  exclusion 
of  light  in  the  treatment  of  small-pox.  He  mentions  an  experiment 
made  in  a  case  of  confluent  small-pox  by  covering  one-half  the  face 
with  a  warm  solution  of  colored  gelatin,  thus  excluding  the  actinic  rays, 
the  rest  of  the  face  being  left  exposed  to  the  full  action  of  light;  the 
result  showed  a  marked  contrast  between  the  two  sides;  the  protected 
side,  being  less  severely  affected,  showed  little  or  no  scarification,  while 
the  part  remaining  free  was  covered  with  deep,  suppurating  lesions  and 
consequent  marked  disfigurement.  Barlow  further  recommends  in  the 
treatment  of  small-pox  that  only  the  actinic  rays  of  the  solar  prism  be 
cut  off,  thus  obviating  the  depressing  effect  on  the  mind  which  total 
darkness  would  probably  cause.  Gallavardin150  reports  his  observations 
on  the  effect  of  excluding  light  in  the  treatment  of  small-pox  during  a 
period  of  seven  years.  The  method  employed  was  to  place  the  patient 
in  total  darkness,  maintaining  that  the  method  is  effectual  only  when 

148  Averroes  (d.  1198),  p.  14. 

"7  Black  (C.):  The  Lancet,  June  29,  1867. 

148  Waters  (J.  H.).:  The  Lancet,  February,  1871. 

"•Barlow  (W.  H.):  The  Lancet,  July,  1871. 

180  Gallavardin:  Lyon  Med.,  1892,  Ixx,  pp.  220  et  seq. 


VARIOLA.  113 

thus  thoroughly  carried  out,  in  which  case  suppuration  and  pitting  are 
prevented.  To  Unna,151  Widmark,152  and  Hammer153  we  are  indebted 
for  valuable  investigations  as  to  the  effect  of  light  in  certain  diseases 
of  the  skin.  These  observers  have  determined  that  it  is  the  chemical 
rays  of  sunlight  which  alone  are  active  in  causing  both  pigmentation 
and  solar  eczema.  Hammer  and  Widmark  have  shown  that  the  same 
phenomena  may  be  observed  from  a  strong  electric  light,  since  it  is 
particularly  rich  in  chemical  rays.  These  observers  have  further  dem- 
onstrated that  the  chemical  rays  constitute  essentially  the  blue  and 
violet,  especially  the  ultraviolet  part  of  the  spectrum,  which  of  all  light 
rays  are  the  most  refrangible.  Under  their  influence  chemical  activity 
is  strongest,  while  caloric  activity  is  weakest.  The  converse  of  this 
holds  true  in  the  other  end  of  the  spectrum,  where  the  red  rays  are 
found.  Thus,  the  ultra-red  rays  were  found  to  be  the  least  refrangible, 
while  with  them  the  caloric  activity  was  greatest  and  chemical  activity 
the  least. 

According  to  Finsen,154  of  Copenhagen,  Lindholm,  Medical  Officer 
of  Health,  and  Svendson,  Visiting  Physician  of  the  Municipal  Hospital, 
during  the  summer  of  1893,  used  either  red  curtains,  which  were  kept 
tightly  closed,  or  windows  of  red  glass  in  the  apartments  occupied  by 
small-pox  patients,  with  gratifying  success.  The  former  states  that 
when  these  precautions  were  thoroughly  carried  out  cedema  quickly 
subsided  and  the  suppurative  fever  failed  to  appear.  There  were  20 
patieinS  thus  treated,  10  of  whom  were  unvaccinated  children,  and  in 
all,  though  severely  attacked,  recovery  took  place.  In  1  case  of  black 
small-pox  the  eruption  dried  up  shortly  after  its  appearance,  no  fever 
or  maturation  took  place  and  only  a  few  scars  were  produced.  Svendson 
has  also  published  an  account  of  the  treatment  of  small-pox  by  means 
of  red  light  during  an  epidemic  at  Bergen,155  in  which  his  former  ex- 
perience was  verified.  Not  only  did  the  vesicles  dry  up  without  be- 
coming purulent,  but  suppurative  fever  was  entirely  prevented,  thus 
rendering  the  disease  less  protracted  as  well  as  less  painful  on  account 
of  the  absence  of  destructive  suppuration.  In  no  case  did  pitting  oc- 
cur. Experiments  were  made  by  allowing  2  patients  who  had  passed 


181  Unna  (P.  G.):  Monats.  f.  prak.  Derm.,  1885,  p.  285. 

152  Widmark :   "Hygiea  Festband,"  No.   3,   and  "Biol.   Foren.   Forhandl.   Verhandl. 
d.  biol.  in  Stockholm,"  1888,  i,  131-134. 

153  Hammer:    "Ueber   den    Einfluss    des    Lichtes    auf    die    Haut."      "Verhandl.    d. 
deutsch.  dermat.  Gesellsch.,"  Wien,  1892,  pp.  329  et  aeg. 

164  Finsen  (N.  R.):  "Om  Lysets  Indvirkninger  paa  Huden,"  Hospitalstidende,  July 
5,  1893;  ibid.,  September  6,  1893. 

156  Svendson:  Medicinsk  Revue,  October,  1893. 


114  THE   ACUTE   EXANTHEMATA. 

through  the  stage  of  desiccation  on  the  face,  the  disease  being  still 
active  on  the  hands,  to  have  free  access  to  daylight,  whereupon  the  le- 
sions on  the  hands  immediately  took  on  a  more  active  condition  re- 
sulting in  suppuration  and  deep  pits  on  the  backs  of  the  hands  in  both 
cases.  He  concludes  by  saying  that  the  clinical  records  of  cases  thus 
treated  show  the  following  important  differences:  The  suppurative 
stage,  which  is  usually  the  most  dangerous  as  well  as  the  most  loath- 
some, passes  over  with  little  or  no  rise  of  temperature  or  oedema,  the 
disease  passing  directly  from  the  vesicular  stage,  which,  in  the  cases 
observed,  seemed  to  be  somewhat  protracted,  to  that  of  desquamation 
and  convalescence.  Furthermore  this  method  prevents  the  disfigure- 
ment of  pitting. 

Juhel-Renoy,156  of  Paris,  has  likewise  experimented  by  excluding 
from  the  room  all  but  the  red  rays  of  light  in  the  treatment  of  small- 
pox. He  expresses  himself  with  more  conservatism  by  saying  that  the 
chemical  rays  of  light  cannot  prevent  suppuration,  but  lessen  it  to  a 
marked  degree,  and  are  capable  of  rendering  the  scarification  resulting 
therefrom  less  disfiguring.  Feilberg,157  of  the  Oresund  Hospital,  Co- 
penhagen, in  an  epidemic  which  occurred  in  1894,  observed  the  effect 
of  excluding  the  chemical  light-rays  in  the  treatment  of  fourteen  cases. 
The  results,  he  claims,  were  satisfactory  and  highly  to  be  recommended. 
J.  W.  Moore  (loc.  cit.,  p.  478),  of  Dublin,  notes  the  effect  of  excluding 
the  chemical  rays  in  a  case  which  developed  the  symptoms  of  con- 
fluent, if  not  haemorrhagic,  small-pox.  He  excluded  all  but  the  red 
rays  by  completely  covering  all  windows  in  the  chamber  with  thick 
red  curtains  which  were  always  kept  drawn,  while  another  red  curtain 
was  hung  before  the  door.  In  this  case  the  secondary  fever  fell  short 
of  the  primary  by  2.2°  F.,  and  the  rash,  while  dark  in  places,  never 
became  markedly  pustular,  although  the  contents  of  the  vesicles  were 
lactescent  and  opaque,  and  showed  signs  of  hemorrhage  in  many  of 
the  lesions.  The  patient  made  a  good  recovery.  Moore  further  states 
that  in  the  epidemic  of  1894-95  patients  admitted  to  the  Cork  Street 
Hospital,  Dublin,  were  subjected  to  the  red-light  method  of  treatment, 
with  the  effect  of  reducing  the  number  of  eye  complications,  and  at 
the  same  time  of  producing  a  light  so  agreeable  that  the  patients  vol- 
untarily spoke  of  the  color  as  "soothing."  The  writer  has  had  occa- 
sion to  observe  the  effect  of  red  light  in  13  cases.  This  was  secured 
by  covering  the  windows  with  thick  red  cloth  and  using  electric  lamps 

1S*  Juhel-Renoy:  Bull,  et  M6m.  de  la  Soc.  MSd.  des  H6p.,  December  14,  1893. 
1B7Feilberg  (C.):  Hospitalstidende,  July  4,  1894. 


VARIOLA.  115 

with  red  globes.  Two  of  the  patients  were  hospital  nurses  who  had 
contracted  the  disease  while  attending  a  patient  supposed  to  be  suffer- 
ing from  an  innocuous  disease.  In  1  the  prodromal  symptoms  were 
severe  and  the  patient  was  isolated  on  the  morning  of  the  second  day. 
On  the  evening  of  the  third  day  the  temperature  reached  105°  F.  (40.5° 
C.).  On  the  fourth  day  the  eruption  appeared,  when  the  fever  sub- 
sided. The  pocks  underwent  the  usual  changes  until  the  third  day  of 
the  eruption,,  when  their  contents  absorbed,  leaving  elevated,  small, 
pea-sized,  transparent,  firm,  typical  horn-pox  lesions.  These  separated 
about  the  fifteenth  to  seventeenth  day.  In  the  second  nurse  the  pre- 
monitory disturbances  were  less  characteristic,  although  in  both  the 
catamenia  were  prematurely  established.  On  the  fourth  day  a  few 
papules  were  observed,  but  which  aborted,  leaving  firm  papules  in  the 
skin.  jSTo.  1  had  never  been  very  successfully  vaccinated,  while  No.  2 
presented  a  slight  reaction  to  the  vaccine  virus.  It  is  impossible  to 
draw  any  definite  conclusions  from  only  a  few  cases,  but,  from  the 
success  already  obtained  by  the  chemical  or  actinic  rays  of  the  solar 
spectrum  in  the  treatment  of  lupus  vulgaris,  we  are  led  to  believe 
that  much  good  may  be  accomplished  by  this  method  in  the  manage- 
ment of  variola,  and  from  the  favorable  reports  already  given  it  as- 
suredly is  worthy  of  further  trial. 

GENERAL  TREATMENT. 

Prodromal  Stage. — The  management  of  the  prodromal  stage  sel- 
dom calls  for  any  special  interference.  Of  the  various  methods  that 
have  been  suggested  for  ameliorating  the  subsequent  symptoms  or  cut- 
ting short  an  attack  of  small-pox,  nothing  has  proved  of  certain  benefit. 
At  one  time  all  patients  entering  the  Cleveland  Small-pox  Hospital 
were  vaccinated  at  the  earliest  possible  moment  and  before  the  matura- 
tion of  the  pocks,  but  we  failed  to  see  that  it  had  any  influence  either 
in  cutting  short  the  disease  or  even  of  modifying  it.  While  this  pro- 
cedure is  advocated  by  Welch,158  others,  among  whom  may  be  men- 
tioned Curschmann  and  MacCombie,  have  found  it  of  no  benefit. 

In  all  cases  as  soon  as  the  symptoms  of  small-pox  appear  it  is  ad- 
visable that  the  patient  keep  to  his  room,  although  in  mild  cases  it  is 
scarcely  necessary  to  confine  him  to  bed.  Until  the  severity  of  the 


IBS  Welch    (W.    M.):    "Small-pox,"    in    "American    System   of   Practical    Medicine" 
(New  York  and  Philadelphia,  1897),  vol.  i,  p.  513. 


116  THE   ACUTE    EXANTHEMATA. 

attack  is  determined,  however,  it  is  advisable  to  conserve  his  energy, 
which  later  may  determine  the  outcome  of  the  disease.  To  relieve  the 
obstinate  vomiting  and  retching  often  observed  at  this  time,  small 
pieces  of  ice  may  be  placed  in  the  mouth.  Avoid  hot  fomentations  or 
mustard  plasters,  lest  they  excite  a  confluent  eruption.  For  severe 
frontal  headache  cold  compresses  or  ice-bags  usually  afford  the  most 
relief.  Active  medication  at  this  time  should  generally  be  avoided, 
although  phenacetin,  5  to  10  grains  (0.33  to  0.7  gramme),  or  the 
hypodermic  injection  of  morphine  may  be  resorted  to  when  severe  pain 
in  the  back,  frontal  headache,  or  excessive  vomiting  persists.  Bleeding, 
purging,  and  sweating,  considered  so  essential  at  one  time,  are  now 
entirely  discarded  and  thought  to  be  injurious  on  account  of  their  de- 
pressing effect.  As  the  fever  rises,  and  during  its  height,  bathing  or 
sponging  with  tepid  water  may  be  grateful,  or  a  sheet  may  be  wrung 
out  of  cold  water  and  wrapped  about  the  patient.  In  bathing  it  is 
advisable  to  begin  with  a  temperature  of  95°  F.  (35°  C.),  and  gradually 
cool  by  adding  cold  water  until  85°  or  even  80°  F.  (26.6°  C.)  is  reached. 
This,  however,  is  seldom  essential  before  the  eruptive  stage,  and  is 
indicated  only  when  the  fever  is  excessively  high.  It  is  always  neces- 
sary to  see  that  the  evacuations  from  the  bowels  are  regular,  and  if 
necessary  a  mild  aperient  should  be  administered.  Salines  are  prefer- 
able, such  as  Hunyadi  water  or  sulphate  of  magnesium.  Water  should 
be  given  to  drink  freely;  iced  water  especially  is  usually  grateful  to 
the  patient,  and  it  tends  to  lessen  the  fever.  Lemonade  is  sometimes 
very  refreshing,  and  may  be  given  freely.  The  diet  should  be  light  and 
of  easy  digestion.  Milk,  meat-broths,  and  gruels  are  to  be  recom- 
mended. 

Eruptive  Stage. — The  management  of  small-pox  during  this  stage 
naturally  depends  on  the  extent  and  character  of  the  eruption,  as  well 
as  on  the  special  symptoms  present.  In  varioloid  no  special  treatment 
is  required,  but  in  the  confluent  and  hasmorrhagic  varieties  both  judg- 
ment and  care  are  necessary.  The  management  of  small-pox  is,  there- 
fore, expectant,  for  no  one  can  predict  at  the  onset  what  form  the  dis- 
ease may  assume,  nor  what  complications  and  sequelae  may  be  encoun- 
tered. During  the  management  of  this  stage,  which  is  usually  by  far 
the  most  serious,  the  sources  of  danger  to  be  guarded  against  are :  first, 
collapse  from  the  severity  of  the  disease;  second,  the  absorption  of  sep- 
tic material  which  is  met  with  as  maturation  progresses;  and,  third, 
complications,  thus  increasing  the  burden,  which  the  already  exhausted 
forces  may  be  unable  to  withstand. 


VARIOLA.  117 

INTERNAL    TREATMENT. 

In  confluent  small-pox  the  patient  should  be  placed  in  bed,  and 
to  maintain  his  strength  diligent  care  must  be  taken  to  select  a  suitable 
dietary.  Food  must  be  taken  at  short,  though  regular,  intervals.  Nour- 
ishment is  usually  called  for  every  two  hours,  although  every  three 
hours  will  suffice  when  larger  quantities  are  taken.  Again,  in  severe 
cases  it  may  be  thought  advisable  that  nourishment  be  administered 
every  hour.  When  the  patient  is  delirious,  or  in  a  stupor,  he  should 
be  aroused  to  enable  him  to  take  nourishment.  When,  however,  he 
falls  into  a  gentle  sleep  he  should  not  be  disturbed.  The  articles  of 
food  best  suited  are  milk,  soft-boiled  or  poached  eggs,  beef-juice,  ani- 
mal broths,  meat  essences,  meat- jellies,  arrowroot,  sago,  custard,  and 
bread.  In  mild  cases,  especially  if  there  is  a  tendency  to  constipation, 
fresh  fruits  may  be  given.  Stewed  or  baked  apples  are  usually  highly 
relished.  Bananas  are  likewise  valuable  in  certain  cases.  When  there 
is  a  tendency  to  diarrhea,  fruit  should  be  withdrawn  and  boiled  milk 
(4  parts),  with  lime-water  (1  part),  may  be  given.  Vermicelli,  gelatin, 
or  arrowroot  may  likewise  be  added  to  the  milk.  If  the  digestive  powers 
are  exceptionally  weak,  the  milk  may  be  peptonized,  the  object  of  which 
is  to  convert  the  insoluble  proteids  and  albuminoids  into  soluble  pep- 
tonoids.  Not  infrequently  when  delirium  is  present  some  difficulty 
may  be  experienced  in  prevailing  upon  the  patient  to  take  sufficient 
nourishment.  At  such  times  it  may  be  necessary  to  administer  it  either 
through  a  tube  introduced  into  the  nares,  passing  down  to  the  oesopha- 
gus, or  by  means  of  nutrient  enemata,  the  latter  being  usually  prefer- 
able. In  using  an  enema  the  rectum  should  first  be  flushed  out  with 
warm  water  and  then  an  enema  of  milk,  or  beef-tea,  or  eggnog,  at  a 
temperature  of  100°  F.  (37.7°  C.),  should  be  given.  The  amount  at 
each  administration  should  not  exceed  from  4  to  6  ounces  (120  to  180 
cubic  centimetres).  As  a  rule,  a  pint  (1/2  litre)  of  animal  broth  or  from 

1  Y2  to  2  pints  (720  to  960  cubic  centimetres)  of  milk  in  twenty-four 
hours  will  be  found  sufficient.    When  more  than  this  is  given,  digestive 
disturbances  are  liable  to  follow.    In  low  forms  an  adult  should  take 
about  2  or  3  quarts  (1920  to  2880  cubic  centimetres)  of  milk  and  from 

2  to  3  raw  eggs  in  twenty-four  hours.    Alcohol  is  sometimes  indicated 
at  this  time,  but  it  should  not  be  given  indiscriminately.    Murchison159 
states  that  patients  under  twenty  years  of  age,  as  a  rule,  do  best  with- 
out alcohol,  whereas  most  patients  over  forty  are  benefited  by  it  after 

168  See  J.  W.  Moore  (lor.  cit.,  p.  482;. 


118  THE   ACUTE    EXANTHEMATA. 

the  first  week.  Intemperate  persons  require  alcohol  early,  and  in 
greater  quantities  than  others;  yet  even  here  there  are  instances  in 
which  it  does  not  agree.  The  chief  indications  as  laid  down  by  Mur- 
chison  for  the  use  of  alcoholic  stimulants  are  derived  from  the  state  of 
the  pulse,  the  heart,  the  effect  on  the  brain,  and  from  the  presence  of 
complications,  and  especially  from  the  typhoid  state  as  evidenced  by 
stupor,  low  muttering  delirium,  tremor,  subsultus,  involuntary  evacua- 
tions, coma-vigil,  etc.  In  short,  alcohol  may  be  considered  as  beneficial 
to  the  patient:  first,  if  under  its  use  the  heart's  action  becomes  stronger 
and  less  rapid,  the  impulse  increasing  in  strength  and  the  first  sound 
becoming  more  distinct;  second,  when  a  soft,  compressible,  undulating, 
irregular,  or  intermitting  pulse  becomes  fuller  and  stronger  and  more 
regular  in  rhythm  and  volume;  third,  if  a  dry,  brown  tongue  becomes 
clean  and  moist  at  the  edges;  fourth,  if  delirium  lessens,  the  patient 
becoming  more  tranquil  or  even  falling  asleep.  It  should  be  remem- 
bered that  the  vitality  of  the  patient  is  lower  during  the  night,  reach- 
ing its  lowest  ebb  about  four  o'clock  in  the  morning.  Stimulants, 
therefore,  are  more  frequently  required  during  the  night,  while  in  the 
forenoon  they  are  more  seldom  called  for.  Whisky  (from  6  to  12 
ounces,  or  180  to  360  cubic  centimetres,  in  twenty-four  hours)  in  the 
form  of  milk-punch  or  eggnog  is  usually  preferred.  In  cases  of  ex- 
treme prostration,  as  in  severe  confluent  small-pox  or  in  the  haemor- 
rliagic  variety,  certain  medicinal  stimulants  or  tonics  combined  with 
alcohol  may  be  given.  Among  those  found  the  most  useful  may  be 
mentioned  carbonate  of  ammonium,  the  different  ethers,  sumbul,  cam- 
phor, musk,  turpentine,  or  quinine. 

The  second  danger  during  the  eruptive  stage  is  the  absorption  of 
septic  substances  from  the  extensive  suppuration  present.  It  would 
be  useless  to  enumerate  the  procedures  that  from  time  to  time  have 
been  proposed  to  obviate  this  danger.  Suffice  it  to  say  that  almost  all 
known  substances  have  been  used  both  externally  and  internally  with- 
out producing  very  striking  results.  Foot160  administered  carbolic  acid 
internally  in  the  form  of  the  sodium  sulphocarbolate,  6-  to  10-  grain 
(0.46  to  0.6  gramme)  doses,  in  water,  every  third  hour.  As  the  usual 
beverage  he  gave  a  drachm  (4  grammes)  of  the  sulphurous  acid  in  a 
wineglassful  or  two  of  iced  water,  and  sprayed  the  larynx,  nares,  and 
upper  air-passages  with  a  weak  solution  of  either  sulphuric  or  carbolic 
acid. 


160  Foot  (A.  W.):   Dublin  Jour,  of  Med.   Sci.,  vol.   liii,   pp.  242  et  seq. 


VARIOLA.  119 

v 

Pepper161  has  advocated  cocaine  in  the  treatment  of  small-pox, 
claiming  that  the  disorganization  of  the  blood  is  generally  less  rapid 
and  less  extensive,  that  the  fever  is  less  severe  and  of  shorter  duration, 
and  that  oftentimes  the  lesions  undergo  incomplete  evolution  or  semi- 
abortion  under  its  use.  He  further  maintains  that  visceral  congestion 
and  inflammation  are  not  so  frequent,  and  that  when  present  they  are 
less  intense.  The  dose  given  for  a  child  five  years  old  is  from  2  to  4 
drops  of  a  4-per-cent.  solution  four  times  during  the  twenty-four  hours, 
and  increased  1  drop  for  each  year  until,  at  the  age  of  twenty,  20  drops 
are  taken  at  the  same  intervals.  The  most  important  drugs,  I  believe, 
are  strychnine  and  the  various  preparations  of  iron.  During  the  epi- 
demic of  1898-1901,  after  testing  numerous  preparations,  we  found  the 
former  by  far  the  most  trustworthy  and  important  of  all  internal 
medicaments.  Strychnine  may  either  be  given  by  the  mouth  or  hypo- 
dermically.  The  dose  should  vary  with  the  age  and  general  indica- 
tions, being  from  yioo  to  1/25  grain  (0.00065  to  0.0026  gramme),  re- 
peated every  three  or  four  hours.  Later  in  the  course  of  the  disease 
the  citrate  of  iron  and  quinine,  in  5-  to  10-grain  (0.33  to  0.7  gramme) 
doses  every  four  hours,  likewise  proved  serviceable.  Trinitrin,  1/100 
grain  (0.00065  gramme),  may  also  be  used  to  tide  over  critical  periods. 
Opium  is  of  value  in  diarrhoea,  and  hypodermic  injections  of  morphine, 
Vs  to  V4  grain  (0.008  to  0.016  gramme),  may  be  given  to  induce  sleep. 
In  children  chloral-hydrate  is  to  be  preferred.  On  account  of  the  irri- 
tating effect  this  drug  has  on  the  pharynx  and  larynx  when  these  parts 
are  implicated  in  the  variolous  process,  Curschmann  recommended  it 
in  the  form  of  an  enema,  in  which  from  1  1/2  to  2  drachms  (6  to  8 
grammes)  are  given  with  8  ounces  (240  cubic  centimetres)  of  water 
or  mucilage.  Digitalis  is  likewise  of  value,  and  may  be  given  with 
advantage  in  certain  cases  of  insomnia,  as  in  the  following,  which  is 
highly  recommended  by  Murchison: — 

IJ  Liquoris  opii  sedativi 3j      (     3.5). 

Tincturse  digitalis  3j      (     3.5) . 

Spts.  aetheris  nitrosi 3ij     (     7.0) . 

Aquae  camphorse   3vj    ( 180.0) . 

M.  Sig. :  A  sixth  part  at  once,  and  afterward  half  a  fluidounce  every 
second  hour  until  the  patient  sleeps. 

Of  the  preparations  of  opium,  the  deodorized  tincture,  5  to  7 
minims  (0.3  to  0.7  cubic  centimetre),  is  one  of  the  best.  To  reduce 


161  Pepper  (E.):  American  Jour.  Med.  Sci.,  March,  1893. 


120  THE    ACUTE    EXANTHEMATA. 

fever  phenacetin,  2  to  3  grains  (0.13  to  0.2  gramme),  every  two  hours 
may  be  taken  until  the  temperature  falls  or  several  doses  have  been 
given.  In  ha?morrhagic  small-pox  iron  in  full  doses  (from  20  to  30 
drops  of  the  tincture  every  three  or  four  hours);  tannic  acid,  5  to  10 
grains  (0.33  to  0.7  gramme);  ergot,  and  turpentine  are  indicated.  Un- 
fortunately in  most  cases  all  efforts  avail  but  little;  but  in  the  writer's 
experience  full  doses  of  turpentine  and  ergot  have  given  the  most 
promising  results.  In  those  cases  Curschmann  has  used  transfusion  of 
blood  without  gratifying  effects,  and,  finally,  J.  "W.  Moore  suggests  the 
inhalation  of  oxygen.  He  recommends  that  the  mouth-piece  be  held 
a  short  distance  away  from,  and  below  the  lips  of,  the  patient. 

When  the  intestinal  mucosa  is  involved,  giving  rise  to  copious  diar- 
rhoea, something  more  than  the  measures  previously  suggested  may  be 
necessary.  In  such  cases  in  addition  to  the  starch  diet,  wet  compresses 
may  be  applied  to  the  abdomen,  or  a  simple  starch  enema,  containing 
10  to  20  minims  (0.6  to  1.2  cubic  centimetres)  of  laudanum,  or  the 
deodorized  tincture  of  opium  (Squibb's),  8  to  10  minims  (0.6  to  0.7  cubic 
centimetre),  may  be  resorted  to.  If  the  evacuations  show  signs  of  blood, 
the  spirit  of  turpentine  in  5-minim  (0.3  cubic  centimetre)  doses  may  be 
given.  When  flatulent  distension  of  the  abdomen  or  hiccough  occurs, 
30-minim  (1.8  cubic  centimetres)  doses  of  tincture  of  sumbul  have 
been  found  highly  serviceable.  Moore  further  recommends  hot  fo- 
mentations, poultices,  turpentine  epithems,  and — above  all — ice  poul- 
tices, which  may  be  made  by  putting  small  pieces  of  ice  between  two 
folds  of  flannel.  Should  these  fail,  an  enema  is  indicated  or  a  long 
tube  should  be  passed  up  the  rectum  so  far  as  possible  in  order  to  give 
vent  to  the  pent-up  gas. 

LOCAL    TREATMENT. 

When  the  eruption  is  confluent,  local  measures  are  highly  impor- 
tant, and  numerous  methods  have  been  recommended  to  meet  the  vari- 
ous indications  of  this  critical  stage.  Stokes,162  of  Dublin,  many  years 
ago  considered  the  three  most  important  indications  for  treatment: 
exclusion  of  air,  keeping  the  parts  moist  to  prevent  hardening  of  the 
scabs,  and  lessening  local  irritation.  Thus,  flexible  collodion  has  been 
used,  and  masks  composed  of  various  substances  have  been  recom- 
mended to  meet  the  first  of  these  indications.  Lewentauer163  recom- 
mends the  employment  of  a  mask  in  the  form  of  a  thick  paste  or  oint- 

182  Stokes  (W.):  Dublfn  Jour,  of  Med.  Scl.,  vol.  liii,  p.  9. 
193  Lewentauer:  Bull.  G6n.  de  Ther.,  No.  32,  1869. 


VARIOLA.  121 

ment,  consisting  of  salicylic  acid,  3  parts;  starch,  30  parts;  and  glyc- 
erin, 70  parts.  Bertrand164  likewise  recommends  a  protective  mixture 
composed  of  1  drachm  (4  grammes)  of  boric  acid  and  1  V2  ounces  (43 
grammes)  of  glycerin.  This  is  best  applied  by  means  of  a  brush.  Some 
German  writers  recommend  the  application  of  a  paste  composed  of 
carbolic  acid,  4  to  10  parts;  olive-oil,  40  parts;  and  prepared  chalk, 
60  parts.  This  is  to  be  spread  on  linen  and  applied  to  the  surfaces 
where  the  eruption  is  most  protracted.  The  application  should  be 
changed  once  in  twelve  hours.  In  France  some  recommend  the  appli- 
cation of  a  mercurial  plaster  (Vigo  plaster),  either  in  the  form  of 
strapping  or  by  smearing  the  parts  with  an  ointment  of  firm  consist- 
ence. J.  W.  Moore  (loc.  cit.)  applies  a  mask  over  the  face,  made  of  lint 
thoroughly  soaked  in  iced  water  and  glycerin,  a  teaspoonful  to  the 
ounce  of  water,  and  covered  with  oiled  silk.  Ihle's  paste — a  mixture 
of  10  grains  (0.7  gramme)  of  resorcin  with  2  drachms  (8  grammes) 
each  of  powdered  starch,  oxide  of  zinc,  lanolin,  and  soft  paraffin — would 
probably  suit  some  cases.  In  the  earlier  stages  of  the  eruption  Moore 
likewise  recommends  antiseptic  and  astringent  dusting-powders,  such 
as  boric  acid,  subgallate  of  bismuth,  refined  Fuller's  earth,  or  a  car- 
bolized  powder  like  the  following: — 

R  Acidi  carbolic!  puri  liquefacti 3ss  (   1.8). 

Zinci  oxidi    3j  (30.0). 

Pulv.  lycopodii Bj  (30.0). 

Misce. 

The  same  writer  further  states  that  Hardwicke,  of  the  Fever  Hos- 
pital, Dublin,  recommends  the  application  of  an  ointment  composed  of 
native  impure  carbonate  of  zinc  and  glycerin.  Marson,  formerly  of 
the  London  Small-pox  Hospital,  waited  until  the  pustules  had  burst 
and  the  discharge  began  to  desiccate,  when  he  applied  olive-oil,  or  a 
mixture  of  glycerin  and  rose-water  in  the  proportion  of  glycerin,  1  to 
3  of  rose-water.  He  also  recommended  cold  cream,  or  oxide  of  zinc  or 
Carron  oil  (a  mixture  of  olive-oil  and  lime-water).  These  are  all  more 
or  less  disagreeable  to  the  patient,  and  are  difficult  to  apply  and  main- 
tain in  position;  besides,  their  application  does  not  produce  the  effect 
which  has  sometimes  been  claimed  for  them.  Of  greater  value  is  ich- 
thyol  (ammonio-sulphate),  which  is  also  well  spoken  of  by  Hoerschel- 
mann.165  It  should  be  used  in  the  strength  of  from  20  to  50  per  cent. 
From  what  has  previously  been  said,  exclusion  of  light  or  its  chemical 

184  Bertrand:  Gaz.  des  HSp.,  July  15  and  17,  1890. 

166  Hoerschelmann  (E.):  St.  Petersburg  med.  Woch.,  1898,  N.  F.,  xv,  pp.  383-386. 


122  THE    ACUTE    EXANTHEMATA. 

rays  probably  has  greater  effect  than  excluding  the  air.  The  second 
indication  as  given  by  Stokes  includes  the  third,  because,  of  all  local 
measures  during  this  painful  stage,  that  of  keeping  the  parts  perma- 
nently moist  is  the  best.  Curschmann  found  cold,  wet  compresses 
applied  to  the  face  and  hands  the  most  grateful  to  the  patient  and 
soothing  to  the  inflamed  skin. 

It  is  seldom  possible  to  give  a  full  bath  in  confluent  small-pox, 
but  when  competent  attendants  and  proper  appliances  are  at  hand, 
the  continued  bath,  first  recommended  by  Hebra  (op.  cit.),  is  highly 
to  be  recommended.  Xot  only  does  it  cleanse  the  surface  and  allay 
fever,  but  the  patient  is  placed  in  the  most  comfortable  environment 
and  recovery  is  facilitated.  It  is  not  unusual  to  see  those  raving  in 
delirium,  or  tortured  by  the  slightest  movement  or  contact  of  cloth- 
ing, fall  into  a  gentle  sleep  soon  after  entering  the  bath.  The  impor- 
tance of  this  procedure  warrants  a  more  detailed  description  of  the 
method  of  its  employment.  An  ordinary  bath-tub  may  be  utilized  for 
this  purpose,  although  in  small-pox  hospitals  the  bath-tub  should  be 
at  least  six  feet  (2  metres)  long  by  three  feet  (1  metre)  broad.  An  iron 
bath-tub  finished  with  enamel  is  the  best,  although  any  material  will 
serve  equally  well.  Within  the  tub  is  an  iron  or  wooden  frame  to 
which  are  fastened  transverse  bands  of  webbing,  such  as  is  used  by 
upholsterers.  About  two  feet  from  one  end  of  this  frame  a  head  sup- 
port is  attached  by  hinges  allowing  it  to  be  placed  at  any  angle  desired 
and  which  may  be  secured  by  means  of  a  ratchet.  This  frame  is  sup- 
ported by  two  cords,  one  at  either  end,  which  pass  over  two  small 
rollers;  so  that  the  whole  may  be  easily  raised  or  lowered  within  the 
bath.  It  is  more  convenient  to  rest  the  frame  on  two  blocks  of  wood, 
which  elevate  it  about  six  inches  (0.15  metre)  from  the  bottom  of  the 
tub;  in  which  case  handles  must  be  fastened  to  the  frame  to  facilitate 
its  removal.  When  hot  and  cold  water  pipes  are  not  supplied,  the 
water  may  be  maintained  at  the  desired  temperature  by  having  a  vessel 
made  of  copper  or  tin  which  can  be  heated.  A  supply-pipe  from  this 
heated  reservoir  should  enter  at  the  bottom  of  the  bath  while  the 
escape-pipe  allowing  the  cold  water  to  flow  away  should  be  placed  at 
the  water-level.  When  the  apparatus  is  in  use  the  water  should  be 
kept  constantly  flowing,  so  that  all  impurities  may  be  washed  away. 
That  the  face  may  be  likewise  submerged  or  irrigated,  small  tubes  pro- 
vided with  a  rose  or  perforated  nozzle  are  connected  with  the  copper 
vessel  or  reservoir.  It  requires  little  mechanical  skill  to  construct  a 
water-bed  suitable  for  the  purpose.  A  blanket,  evenly  folded  and 


VARIOLA.  123 

placed  upon  the  frame,  together  with  a  hair  pillow  on  the  head-rest, 
completes  the  bed.  Before  entering  the  hath  the  tub  should  be  filled 
with  water  at  a  temperature  ranging  from  90°  to  100°  F.  (32.2°  to 
37.7°  C.),  according  to  the  needs  of  the  patient.  It  may  be  said  that 
the  object  is  usually  not  so  much  to  lower  the  temperature  as  it  is  to 
furnish  a  detergent  and  soothing  environment  to  the  patient.  It  is 
useful  to  have  a  wooden  cover  upon  which  a  blanket  is  spread  to  put 
over  the  lower  part  of  the  bath  to  prevent  too  rapid  cooling.  If  desir- 
able the  head  may  likewise  be  covered  by  hooping  over  the  bath-tub 
upon  which  the  blanket  may  be  placed.  The.  patient  should  be  allowed 
to  remain  in  this  bath  for  at  least  several  hours,  sometimes  seven  or 
more,  each  day,  and  if  no  centra-indications  arise  it  may  be  prolonged 
indefinitely,  provided  the  patient  is  removed  for  the  calls  of  nature. 

For  the  purpose  of  fully  carrying  out  local  asepsis,  Foote  (loc.  cit.) 
covered  the  face  with  carbolized  oil  and  sponged  the  body  with  solu- 
tions of  sulphurous  acid,  and  sulphur  was  frequently  burnt  in  the 
room.  Telamon166  applied  ethereal  solutions  of  various  antiseptics  in 
the  form  of  a  spray.  He  recommends  salol  when  the  rash  is  slight  and 
scanty,  but  in  severe  cases  corrosive  sublimate  is  to  be  preferred.  Thus, 
the  part  may  be  sprayed  for  a  minute  three  or  four  times  a  day,  until 
desiccation  takes  place,  with  a  solution  consisting  of  corrosive  sublimate 
and  citric  acid,  of  each,  15  grains  (1  gramme);  alcohol  (90  per  cent.), 
80  minims  (5  cubic  centimetres),  and  ether,  sufficient  to  make  1  Y2 
ounces  (50  cubic  centimetres).  The  eyes  should  be  guarded  during 
the  application. 

It  has  been  observed  that  at  the  onset  of  the  disease  anything  that 
causes  a  determination  of  blood  to  the  skin  increases  the  eruption,  and, 
conversely,  that  depleting  measures  lessen  the  size  and  number  of  the 
pocks.  For  this  reason,  the  writer  has  found,  after  numerous  trials, 
the  most  efficient  local  treatment  in  a  large  number  of  cases  to  be  as 
follows:  A  felt  or  lint  mask  with  apertures  cut  for  the  eyes,  nose,  and 
mouth,  should  be  saturated  with  iced  water  and  applied.  To  be  ef- 
fectual it  must  be  used  early,  before  the  eruption  appears  and  con- 
tinued with  frequent  changing  until  the  stage  of  desiccation.  As  soon 
as  it  can  be  determined  that  the  eruption  will  be  confluent,  when  the 
fever  remains  high,  the  scalp  and  beard  should  be  closely  clipped,  and 
cool  sponging  or  cold  compresses  to  the  confluent  parts  should  be  re- 
sorted to  as  early  in  the  eruptive  stage  as  possible.  As  the  pocks 


188  Telamon:  Med.  Mod.,  April  17,  1890. 


124  THE    ACUTE    EXANTHEMATA. 

mature,  a  saturated  aqueous  solution  of  boric  acid  may  be  used  in  the 
same  way,  or,  in  some  instances,  especially  when  suppuration  com- 
mences, a  solution  of  corrosive  sublimate  (1  to  2000)  or  carbolized  water 
(1  to  2  per  cent.)  may  be  preferred.  To  be  of  service  such  applications 
should  be  made  at  short  intervals  and  the  compresses  changed  every 
fifteen  or  twenty  minutes.  When  practicable,  tense  pustules  should 
be  ruptured  with  a  lancet  and  the  cavity  flushed  out  with  one  of  the 
antiseptic  solutions  previously  mentioned  by  means  of  a  fine-nozzled 
syringe.  As  the  active  suppurative  stage  subsides,  a  full,  warm  bath, 
in  which  the  water  is  tinged  with  permanganate  of  potassium,  is  to 
be  recommended.  It  should  be  remembered  that  the  potassium  per- 
manganate is  rendered  inert  by  soap  or  any  organic  matter. 

In  children  the  convulsions  which  frequently  supervene  are  best 
treated  by  warm  baths.  Not  only  may  the  best  results  be  secured  in 
this  way,  but  they  are  measures  found  most  agreeable  to  the  patient, 
which  of  itself  may  be  well  worth  considering.  It  is  highly  important 
that  the  crusts  be  separated  as  soon  as  possible,  so  that  a  more  direct 
application  of  soothing,  antiseptic  dressings  may  be  made.  This  is 
more  especially  true  of  the  face  and  hands.  Water  dressings  may  now 
be  replaced  by  some  bland,  oily  substance,  such  as  olive-oil  or  vaselin, 
to  which  boric  acid  (25  per  cent.),  carbolic  acid  (1  to  2  per  cent.),  or 
mercury  (white-precipitate  ointment,  5  per  cent.)  has  been  added.  Al- 
though in  the  majority  of  cases  it  is  impossible  to  wash  the  patient  to 
any  extent  during  the  active  eruptive  stage,  yet  as  incrustation  and  de- 
crustation  set  in,  the  tepid  bath,  from  one-half  to  one  hour  in  duration, 
may  be  given  daily  with  the  view  of  facilitating  the  separation  of  crusts 
and  cleansing  the  skin,  after  which  it  should  be  anointed. 

When  abscesses  form  they  are  to  be  opened  early  with  a  free  in- 
cision, allowing  no  accumulation  of  pus  to  occur,  and  taking  care  that 
such  cavities  or  sacks  are  thoroughly  irrigated  with  the  bichloride  or 
boric  solutions  previously  referred  to.  When  pus  oozes  from  ruptured 
pocks  it  should  be  also  cared  for  by  frequent  sponging.  A  solution  of 
nitrate  of  silver  has  frequently  been  recommended,  but  the  writer  must 
concur  with  MacCombie,  that  never  has  he  been  able  to  observe  the 
slightest  benefit  from  its  use.  The  same  may  be  said  of  dusting- 
powders.  WThen  the  eruption  on  the  face  gives  rise  to  severe  itching, 
resorcin  (3  per  cent.)  or  carbolic  acid  (2  per  cent.)  should  be  applied, 
or  it  may  be  necessary  to  muffle  the  hands  to  prevent  further  disfigure- 
ment from  scratching.  When  the  early  separation  of  the  crusts  cannot 
be  accomplished  by  the  moist  dressings  previously  recommended,  the 


VARIOLA.  125 

application  of  linseedmeal  poultices  may  be  advised.  On  the  scalp  a 
thick  poultice  with  iodoform  sprinkled  on  the  surface  may  be  applied 
in  the  ordinary  manner,  but  on  the  face  the  method  most  agreeable 
to  the  patient  is,  according  to  MacCombie  (loc.  cit.),  as  follows:  As 
desiccation  takes  place,  a  mask  is  made  of  a  single  thickness  of  lint  with 
apertures  for  the  eyes,  nose,  and  mouth.  A  thin  layer  of  linseed  poul- 
tice is  smeared  upon  this,  taking  care  to  put  on  the  surface  a  little 
vaselin,  with  which  iodoform  has  been  mixed,  and  applied  to  the  face, 
changing  at  least  every  two  hours.  By  this  means,  according  to  this 
author,  the  crusts  may  be  separated  more  rapidly  than  by  any  other 
method.  On  the  legs,  arms,  and  elsewhere  a  solution  of  boric  acid  or 
other  watery  antiseptic  dressings,  followed  by  carbolized  vaselin,  will 
be  found  sufficient  in  the  great  majority  of  cases. 

During  the  stage  of  exudation  particular  attention  should  be  given 
to  the  eyes.  The  aperture  of  the  lids  is  often  completely  closed  from 
ffidema,  allowing  secretions  to  be  retained  which  frequently  decom- 
pose and  set  up  a  severe  conjunctivitis.  Moreover,  small-pox  lesions 
may  occur  upon  the  conjunctiva,  and,  as  previously  shown,  not  infre- 
quently pursue  a  very  rapid  course;  therefore  the  frequent  inspection 
of  the  eyes  is  imperative.  In  simple  conjunctivitis  the  lids  should  be 
elevated  and  the  eye  irrigated  every  hour  or  oftener  with  a  saturated 
aqueous  solution  of  boric  acid,  or  the  following: — 

IJ  Sodii  chloridi    gr.  viij   (     0.52) . 

Acidi  borici  3j  (     4.00) . 

Aquje  dest f^iv          (120.00). 

Misce  et  filtra. 

In  more  urgent  cases  a  solution  of  corrosive  sublimate  (1  to  2000) 
may  be  dropped  into  the  eye  once  or  even  twice  daily.  Again,  that  the 
eye  may  be  placed  at  rest,  atropia  may  be  called  for: — 

IJ  Atropise   sulph gr.  ij    (  0.13). 

Aqua;  dest f3iv      (16.00). 

Misce. 

A  drop  may  be  instilled  into  the  eye  every  half-hour  or  until  full 
dilatation  is  produced,  after  which  twice  a  day  will  be  sufficient  to 
maintain  the  relaxation  thus  produced. 

The  use  of  the  silver  nitrate  is  growing  less  in  favor,  although  it 
is  highly  recommended  by  some  in  severe  conjunctivitis  attending  this 
disease.  It  may  be  employed  in  the  strength  of  10  grains  (0.7  gramme) 
to  1  ounce  (30  cubic  centimetres)  of  distilled  water.  After  its  use, 
however,  the  eye  should  immediately  be  flushed  with  a  2-per-cent. 


126  THE   ACUTE    EXANTHEMATA. 

solution  of  the  sodium  chloride.  When  pustules  form  on  the  cornea, 
they  must  be  incised  at  once,  and  to  relieve  tension  the  knife  should 
be  passed  deeply  into  their  base,  after  which  the  eye  may  be  flushed 
with  a  warm,  saturated  solution  of  boric  acid,  followed  by  a  solution 
of  mercuric  chloride  (corrosive  sublimate),  which  should  be  dropped 
into  the  eye  once  or  twice  daily.  In  the  meantime  the  solution  of  boric 
acid,  previously  recommended,  should  be  used  freely  every  hour  or  as 
occasion  demands.  When  ulceration  takes  place,  a  strong  solution  of 
corrosive  sublimate  (1  to  500)  may  be  used.  This  is  applied  once  or 
twice  daily  by  means  of  a  fine  pledget  of  cotton,  wound  around  a  tooth- 
pick. It  is  advisable,  before  making  this  strong  application,  to  use 
a  4-per-cent.  solution  of  cocaine  to  deaden  the  sensibility.  In  these 
cases  mydriasis  should  be  maintained  by  atropia,  as  previously  de- 
scribed. In  all  cases  it  is  advisable  to  keep  the  room  fairly  dark,  al- 
though the  light  should  vary,  being  lighter  during  the  day  than  at 
night.  The  red  glass  previously  referred  to  is  useful  in  obviating  eye- 
complications.  When  ulceration  of  the  cornea  takes  place,  atropine 
and  cold  compresses  must  be  used.  If  perforation,  staphyloma,  or  ex- 
tensive purulent  iridocyclitis,  or  panophthalmitis  occur,  the  services  of 
an  ophthalmic  surgeon  should,  if  possible,  be  obtained.  Fortunately, 
destructive  changes  in  the  eye  are  far  from  common,  and  especially  if 
the  precautions  herein  given  are  carried  out. 

The  nose  and  mouth  must  likewise  receive  attention,  and  frequent 
cleansing  of  the  parts  may  become  necessary.  The  mouth  may  be 
swabbed  out  with  a  saturated  solution  of  boric  acid,  while  in  the  nos- 
trils it  may  be  used  in  the  form  of  a  spray.  Glyceride  of  tannin,  1  part, 
and  distilled  hamamelis,  3  parts,  is  an  excellent  application  for  this 
purpose.  MacCombie  recommends  a  mouth-wash  composed  of,  the 
liquor  of  potassa  and  pure  carbolic  acid,  of  each,  1  part,  to  80  parts  of 
water.  This  may  be  further  diluted,  if  necessary,  especially  in  the  case 
of  children.  If  laryngitis  exists,  iced  compresses  to  the  throat  may  be 
made,  or  a  tent  so  arranged  by  means  of  a  sheet,  in  which  steam  or 
warm  inhalations  are  introduced,  that  the  patient  may  inhale  both 
heat  and  moisture.  When  dyspnoea  is  great  or  when  redema  of  the 
glottis  occurs,  if  not  relieved  by  this  method,  tracheotomy  may  be 
called  for.  This  operation  is  rendered  extremely  difficult  in  small-pox, 
on  account  of  the  redema  present  and  the  excessive  haemorrhage  which 
is  liable  to  take  place.  Glossitis  seldom  requires  any  special  interfer- 
ence; usually  the  application  of  finely  powdered  ice  is  sufficient;  but, 
if  the  swelling  is  great,  it  may  be  necessary  to  make  free  incisions, 


VARIOLA.  127 

about  half  an  inch  in  depth  and  one  to  two  inches  in  length.  If  ery- 
sipelas occurs,  the  parts  should  be  covered  with  equal  parts  of  ichthyol 
and  vaselin,  or  ichthyol  may  be  applied  pure,  after  which  the  parts 
may  be  enveloped  in  cotton-wool.  In  case  of  cellulitis,  if  extensive, 
deep  incisions  must  be  made  early,  followed  by  antiseptic  flushings  or 
hot  fomentations.  To  assist  the  skin  in  regaining  its  natural  condition 
after  the  small-pox  lesions  have  disappeared,  I  have  frequently  given 
the  following: — 

!£  Sulphuris  prsecipitati  3iij         (11.25). 

Acidi  salicylici  gr.  xx   (     1.3). 

Glycerin!, 

Alcoholis aa  q.  s.  ad  fjiij        (  90.0) . 

M.     Sig. :    Apply  at  night. 

This  should  be  washed  off  with  warm  water  and  soap  in  the  morn- 
ing, after  which  the  following  may  be  applied  with  a  pledget  of  cotton 
three  or  four  times  a  day: — 

IJ  Acidi   borici    3iv  (   16.00) . 

Acidi  salicylici  gr.  xv  (     0.98). 

Spts.   lavandulse    f3ij  (     0.70). 

Alcoholis   f^vj  (180.00). 

Misce. 

Finally,  it  is  to  be  borne  in  mind  that  the  treatment,  both  of  the 
complications  and  sequela?  of  small-pox,  does  not  differ  from  that  em- 
ployed in  similar  conditions  unaccompanied  by  variola. 


CHAPTER  III. 

VACCINIA. 

THE  deplorable  condition  which  obtained  during  the  latter  part 
of  the  eighteenth  century  relative  to  the  prevalence  of  small-pox  ren- 
dered any  measure  that  promised  relief  to  be  hailed  with  joy.  The 
practice  of  inoculating  a  disease  so  loathsome  and  frightful  in  its  con- 
sequences, which,  under  the  most  favorable  conditions,  was  more  or  less 
severe,  often  resulting  in  disfiguring  scars  and  sometimes  fatally  (vari- 
ously estimated  at  about  2  in  1000)  could  not  be  generally  introduced. 
Those  who  subjected  themselves  to  inoculation,  therefore,  were  the 
means  of  spreading  the  pest  to  the  great  mass  of  their  unprotected 
fellows,  who  then  contracted  the  disease  in  the  regular  way.  This  ex- 
plains the  prevalence,  as  well  as  the  high  mortality,  of  small-pox  at  this 
time.  It  was  generally  known  that  the  court  ladies  and  other  devotees 
of  fashion  looked  with  enmity  upon  the  immunity  enjoyed  by  some 
of  the  dairy-maids  in  Gloucestershire  to  the  pitting  of  small-pox. 
Long  before  Jenner's  time  it  is  related  of  the  Duchess  of  Cleveland, 
who  held  a  position  in  the  service  of  King  Charles  I,  the  chief  function 
of  which  was  in  close  dependence  upon  her  beauty,  that,  when  joked 
by  the  courtiers  on  the  possible  loss  of  her  occupation  through  the  dis- 
figurement of  small-pox,  she  replied  that  she  had  nothing  to  fear,  for 
she  had  had  the  cow-pox.  A.  von  Homboldt  is  said  to  have  observed 
the  practice  of  vaccination  as  a  protective  measure  against  small-pox 
long  before  among  the  mountaineers  of  Mexico,  and  in  Europe  it  was 
mentioned  by  Siilzer  in  1713,  and  by  Sutton  and  Fewster  in  1765167; 
yet  it  is  highly  probable  that  its  actual  value  remained  unknown. 

Jenner,  while  yet  a  student  at  Sudbury,  observed  the  immunity 
to  small-pox  enjoyed  by  farm-hands  and  dairy-maids  who  had  pre- 
viously contracted  sores  on  their  hands  from  milking  cows  having  pust- 
ules on  their  teats  and  udders,  known  as  kine-pox.  So  far  as  known, 
however,  vaccination  was  performed  the  first  time  with  this  end  in 
view  by  one  Jesty,  a  Dorsetshire  farmer,  in  1774,  who,  having  seen  the 
result  of  inoculation  with  cow-pox  and  knowing  its  protective  value, 
submitted  himself  with  his  entire  family  to  vaccination  for  the  purpose 
of  protection  against  the  small-pox.  This  unsuspecting  pioneer  in  the 

187  See  Curschmann  (loc.  cit.,  p.  401). 

(128) 


VACCINIA.  129 

domain  of  science  afterward  presented  himself  at  the  Inoculation  Hos- 
pital in  London,  and  defied  the  physicians  to  give  him  or  any  of  his 
family  the  small-pox.  The  physicians  in  attendance  failed  to  observe 
anything  extraordinary  in  this  procedure;  hence  it  was  left  to  Jenner, 
a  pupil  of  the  great  John  Hunter,  to  utilize  the  great  principles  thus 
set  forth,  which  was  destined  so  soon  to  revolutionize  the  methods  of 
combating  the  pest.  Following  up  the  observations  made  in  his  youth 
by  painstaking  experiments,  Jenner168  finally,  in  1798,  announced  to 
the  world  the  principles  of  what  he  termed  variolce  vaccina.  Unques- 
tionably, therefore,  to  Edward  Jenner  belongs  the  credit  of  the  gen- 
eral practice  of  vaccination.  In  1799  the  first  public  institution  for 
vaccination  was  established  in  London.  In  1800  it  was  introduced  into 
France  and  Germany.  In  1807,  on  account  of  numerous  and  spirited 
controversies  as  to  the  merits  and  demerits  of  the  new  custom,  a  com- 
mission was  appointed  by  the  Eoyal  College  of  Physicians  to  investigate 
all  known  facts  relative  to  the  subject  of  vaccination.  In  reviewing 
the  effects  in  several  hundred  thousand  cases,  the  conclusion  arrived 
at  was  that,  though  in  some  instances  vaccination  failed  to  protect,  it 
afforded  greater  security  against  small-pox  than  the  inoculation  pre- 
viously in  use,  while  the  illness  introduced  by  it  was  milder  and  less 
hazardous.169 

DEFINITION. 

Vaccinia  is  an  acute,  eruptive  disorder  in  man,  caused  by  the  in- 
oculation of  lymph,  derived  from  a  sero-purulent  eruption  sometimes 
met  with  on  the  teats  and  udders  of  cows,  and  known  as  cow-pox.  The 
virus  is  propagated  either  by  vaccinating  from  one  person  to  another, 
or  by  similar  cultivations  in  the  bovine  species.  The  lesions  are  one 
or  more  in  number,  according  to  the  points  of  inoculation,  and  un- 
dergo changes  similar  to  those  observed  in  variola.  It  completes  its 
course  in  about  three  weeks,  and  for  several  years  renders  the  subject 
immune  to  small-pox.  Although  vaccinia  has  been  the  subject  of  dili- 
gent inquiry,  its  real  nature  has  never  been  clearly  set  forth.  The 
identity  of  the  disease  which  appears  on  the  teats  and  udders  of  milch 
cows,  and  that  observed  on  the  hocks  of  horses,  known  as  the  "grease," 
or  "sore  heels,"  has  long  since  been  known,  but  their  relation  to  small- 
pox has,  during  the  whole  nineteenth  century,  evaded  the  most  pains- 


188  Jenner  (E.):  "Inquiry  into  the  Causes  and  Effects  of  Variolae  Vaccinse"   (Lon- 
don, 1798). 

169  "Report  of  the  Royal  Commission,"  p.  13. 


130  THE    ACUTE    EXANTHEMATA. 

taking  research.  It  was  formerly  believed  that  foot-rot,  or  foot-and- 
mouth  disease,  met  with  in  sheep,  as  well  as  an  affection  seen  in 
monkeys,  were  identical  with  cow-pox,  but  the  experiments  of  Hurtrel 
d'Arboval  proved  that  they  bear  no  protective  relationship  to  each 
other,  and  that  the  two  diseases  are  entirely  distinct.  As  to  the  rela- 
tionship between  small-pox  and  cow-pox,  the  experiments  of  Depaul170 
led  him  to  affirm  that:  "First,  there  is  no  vaccine  virus.  Second,  the 
alleged  vaccine  virus  which  is  regarded  as  antagonistic  to  the  variolous 
virus  is  nothing  less  than  the  variolous  virus  itself.  Third,  the  bovine 
and  equine  species  are  subject  to  an  eruptive  disease  which  is  identical 
as  regards  its  nature  with  small-pox  in  man."  According  to  Depaul, 
therefore,  horse-pox,  cow-pox,  vaccinia,  and  variola  are  identical  affec- 
tions, all  having  small-pox  as  their  common  source.  This  observer  fur- 
ther states  his  belief  that  these  affections  are  one  and  the  same  disease, 
which  change  in  form  and  development,  some  developing  completely, 
others  incompletely,  according  as  it  affects  one  or  the  other  animal; 
and,  further,  that  the  virus  of  one  form  of  the  disease  may  be  changed 
into  that  of  another,  when  it  is  transferred  to  the  soil  proper  to  the 
last.  On  the  other  hand,  Chauveau  and  his  colleagues  of  the  commis- 
sion appointed  by  the  Society  of  Medical  Sciences  of  Lyons,  to  ascer- 
tain by  experimental  methods  the  true  relationship  between  small-pox 
and  cow-pox,  have  endeavored  to  prove  the  absolute  non-identity  of 
variola  and  vaccinia.  For  this  purpose  thirty  cows  and  heifers  were 
inoculated  with  small-pox  matter,  which  in  not  a  single  instance  gave 
rise  to  the  typical  vaccine  vesicle,  although  it  produced  a  specific  effect 
which  the  Committee  reported  was  not  cow-pox,  but  was  of  the  nature 
of  small-pox,  although  it  differed  from  its  manifestations  as  observed 
in  man.171  More  recently  Voigt,172  King,173  Hime,17*  and  Simpson175 
have  demonstrated  that,  by  repeating  the  inoculation,  the  variolous 
matter  produces  in  some  instances  a  typical  vaccine  vesicle  after  the 
second  generation,  or  in  one  or  more  removes  from  the  human  subject. 
Viewed  bacteriologically,  Welch176  regards  vaccinia  as  a  modified 
small-pox,  changed  in  passing  through  the  system  of  the  cow.  He 
further  remarks  that  it  has  been  proved  again  and  again  that  small- 

70  Depaul:  Bull,  de  1'Acad.  de  Med.,  December  1    1863,  et  seq. 

71  "Comptes  rendus  ae  la  Soc.  M6d.  de  Lyon,"  tome  v. 

72  Voigt.      See    Copeman:    "Pathology   of   Vaccinia,"    in    the    "Twentieth    Century 
Practice  of  Medicine,"  vol.  iii,  p.  640. 

78  King:  "Trans.  Southern  Indian  Branch  Brit.  Med.  Assoc.,"  1891,  vol.  iv,  No.  1. 

74  Hime:  Brit.  Med.  Jour.,  1892,  vol.  li,  p.  117. 

78  Simpson:  Indian  Med.  Gaz.,  May,  1892. 

"Welch  (W.  H.):  "Trans.  Amer.  Public  Health  Assoc.,"  1889. 


VACCINIA.  i  131 

pox  can  be  conveyed  to  the  cow,  young  heifers  being  especially  sus- 
ceptible. 

From  the  foregoing  and  from  analogy  we  have  reason  to  believe 
that  small-pox  and  cow-pox  are  originally  derived  from  a  common 
source,  and  that  small-pox  may  become  modified  in  its  transmission 
through  the  organism  of  the  cow  in  such  a  manner  as  to  produce  vac- 
cine virus;  in  other  words,  that  the  vaccine,  as  obtained  from  the  cow, 
is  a  product  of  small-pox,  modified  in  its  transmission  through  another 
species. 

SYMPTOMATOLOGY. 

The  ordinary  phenomena  observed  after  the  introduction  of  the 
vaccine-virus  may  be  given  in  the  order  of  their  appearance.  At  the 
point  of  inoculation  nothing  is  usually  seen  excepting  a  slight  redness, 
which  usually  subsides  within  a  day  or  two,  until  the  end  of  the  third 
day.  This  interval  is  called  the  PERIOD  OF  INCUBATION.  On  the  morn- 
ing of  the  third  or  fourth  day  a  distinct  redness  may  be  observed,  which, 
in  a  few  hours,  develops  into  pale-reddish  papules  at  the  seat  of  inocula- 
tion. During  the  fifth  day  the  epidermis  becomes  raised  by  the  collec- 
tion of  a  serous  exudate,  forming  a  whitish  or  bluish  ring  about  the 
entire  lesion,  which  thus  presents  a  central  depression,  or  umbilication. 
This  is  known  as  the  PERIOD  OF  ERUPTION.  This  enlarges  on  the  sixth 
day  and  forms  a  distinct  vesicular  projection  above  the  level  of  the  sur- 
rounding skin.  On  or  about  the  seventh  day  the  underlying  derma 
may  be  felt  as  a  distinct  indurated  zone  when  grasped  between  the 
thumb  and  finger.  The  vaccine  lesion  reaches  its  height  on  the  eighth 
or  ninth  day,  when  it  is  spoken  of  as  mature,  sometimes  also  as  the 
PERIOD  OF  SECRETION.  It  is  stated  by  Mortimer177  that  the  vaccinal 
pock  matures  more  slowly  in  the  African  race,  its  development  being 
from  eleven  to  thirteen  days.  If  the  vesicle  is  ruptured  at  this  time  a 
clear,  unctuous,  or  slightly  gummy  fluid  escapes,  although  several 
punctures  are  necessary  to  evacuate  the  entire  contents,  which  resem- 
bles that  observed  in  the  variola  pustule  and  is  due  to  the  same 
anatomical  conformation.  At  this  time  the  lymph  should  be  collected 
for  future  use.  When  the  sac  is  left  intact  the  vesicular  contents  soon 
assumes  a  turbid  or  opalescent  appearance,  and  the  lesion  presents  a 
rounded  contour,  which  projects  at  the  margin,  while  the  top  assumes 
a  flattened  or  plateau-like  surface.  This  stage  is  often  called  purulent 
transformation,  or  STAGE  OF  SUPPURATION. 


177  Mortimer:  The  Lancet,  April,  1874,  p.  219. 


132  THE   ACUTE    EXANTHEMATA. 

In  size  the  pustule  varies  according  to  the  surface  exposure  to  the 
vaccine-virus,  but  usually  attains  a  diameter  of  a  quarter  to  half  an  inch 
(6  to  12  millimetres),  and  is  accompanied  by  marked  oedema  of  the 
surrounding  structures.  The  neighboring  lymphatic  glands  are  often 
enlarged,  and  a  rise  of  temperature  of  two  or  three  degrees  is  not  un- 
common. At  this  time,  too,  the  feeling  of  malaise,  which  usually  ac- 
companies the  development  of  the  lesion,  now  takes  on  a  more  pro- 
nounced form,  and  the  patient  may  be  indisposed  or  even  ill  for  a  day 
or  two.  This,  however,  soon  passes  away,  and  the  oedema  disappears, 
together  with  the  umbilication  and  inflammatory  areola.  These  symp- 
toms are  often  observed  to  be  less  severe  in  children  than  in  adults.  On 
the  tenth  or  eleventh  to  the  fourteenth  or  fifteenth  day  the  symptoms 
rapidly  subside,  constituting  the  PERIOD  OF  DESICCATION.  At  this  time 
the  lesion  appears  as  a  wrinkled,  dry,  brownish  crust,  which  first  de- 
velops in  the  centre  of  the  lesion  about  the  thirteenth  day,  and  grad- 
ually takes  on  a  blackish  hue,  shrivels  at  the  margins,  and  drops  off 
from  the  twenty-third  to  the  twenty-eighth  day.  This  final  stage  is 
called  PERIOD  OF  CICATRIZATION.  The  scar  left  is  at  first  red,  but  fades 
until  a  whitish,  pitted  (foveated)  mark  remains.  According  to  Fiirst,178 
there  is  an  increase  in  the  number  of  white  blood-cells  during  the  active 
period  of  vaccinia. 

ANOMALOUS  VACCINIA. 

In  many  cases  of  vaccination  the  symptoms  differ  from  the  fore- 
going. This  departure  from  the  normal  may  depend  either  on  the 
attenuation  of  the  vaccine  matter,  on  the  resistance  encountered,  or  on 
some  peculiarity  in  the  person  vaccinated.  There  are  few  people  who 
are  not  susceptible  to  vaccination.  Spalding179  reports  a  case  in  which 
he  performed  vaccination  ten  times  before  a  successful  result  was  ob- 
tained, while  Garrot180  made  thirteen  futile  attempts  before  meeting 
with  success.  According  to  d'Espine,181  the  vaccinal  immunity,  or  in- 
susceptibility to  the  action  of  the  vaccine  virus,  occurs  in  less  than  1 
per  cent,  of  all  cases.  Neither  age,  sex,  nor  bodily  condition,  aside  from 
a  previous  attack  of  variola  or  vaccinia,  has  any  influence  on  the  re- 
ceptivity of  the  virus.  The  foetus  in  utero  is  not  affected  by  maternal 
vaccination.  Thus,  of  50  vaccinations  of  newborn  children  whose 


178  Furst:  "Die  Pathologie  der  Schutz-Pocken-Impfung"  (Berlin,  1896),  p.  21. 

179  Spalding  (H.):  Jour.  Amer.   Med.  Assoc.,  1899,  p.  1230. 

180  Garrot  (E.):  Jour.  Amer.  Med.  Assoc.,  1899,  p.  1230. 

181  D'Espine:  "Vaccine,"  in  "Dictionnaire  de  Med.  et  de  Chir.  Pract.,"  1885. 


VACCINIA.  133 

mothers  had  been  successfully  vaccinated  during  gestation  at  the  Ma- 
ternity Hospital  at  Lille,  Dubequet182  obtained  44  positive  results. 

In  many  cases  of  revaccination  the  vaccinal  pocks  do  not  follow 
the  regular  course  previously  described.  This  is  influenced  largely  by 
the  length  of  time  which  has  elapsed  since  the  previous  vaccination. 
Thus,  the  period  of  incubation  is  subject  to  great  variations,  the  pock 
sometimes  appearing  on  the  second  day,  at  other  times  not  showing 
itself  until  the  seventh  or  eighth,  or  as  high  as  the  thirtieth  day,183 
after  inoculation.  For  this  reason  it  is  not  infrequent  that  a  physician 
vaccinates  the  second  time,  thinking  the  first  has  not  been  successful, 
when  he  observes  the  two  eruptions  appearing  almost  simultaneously. 

VACCINOID,  OR  FALSE  VACCINIA.  —  The  eruption,  or  vaccine 
papule,  as  sometimes  observed,  fails  to  reach  maturity.  Both  Trous- 
seau (loc.  cit.,  pp.  121  et  seq.)  and  Dumont-Pallier184  have  studied  this 
condition  and  speak  of  it  as  bearing  the  same  relation  to  true  vaccinia 
that  varioloid  bears  to  variola.  They  believe,  further,  that  it  develops, 
like  varioloid,  on  a  soil  which  is  not  absolutely  sterile,  but  unfit  for 
the  complete  development  of  the  inoculated  virus.  The  former  pro- 
posed to  designate  it  false  vaccine,  or  false  cow-pox,  a  condition  anal- 
ogous to  varioloid,  and  possessing  immunizing  power  similar  to  that 
affection.  Herviteux,  in  a  communication  to  the  Academy  of  Medicine 
of  Paris  in  1893,  concurred  in  the  opinion  that  vaccinoid  transmits 
by  inoculation  true  vaccine,  and  that  consequently,  like  vaccinia,  it 
confers  immunity  to  small-pox.  According  to  this  observer,  three 
types  of  false  vaccinia  may  be  observed,  dependent  on  the  degree  of 
weakening  of  the  virus  or  the  amount  of  resistance  encountered. 

In  the  first  type  a  pink  papule  appears  at  the  point  of  inoculation, 
which  is  not  accompanied  by  any  marked  inflammation,  and  disap- 
pears in  the  course  of  a  few  days,  leaving  no  scar. 

The  second  form  is  more  active  than  the  preceding.  The  papule 
is  elevated  above  the  surrounding  skin,  of  a  reddish  color,  and  sur- 
rounded by  a  distinct  areola.  A  small  vesicle  often  forms  on  the  sum- 
mit of  the  papule,  which  desiccates,  leaving  a  small  crust,  which  falls 
off  without  producing  a  cicatrix. 

The  third  type  is  still  more  severe,  leaving  a  cicatrix,  which  finally 
disappears. 


182  Dubequet.     See  Brouardel:  "Vaccinia,"  in  the  "Twentieth  Century  Practice  of 
Medicine,"  1898,  vol.  xiii,  p.  520. 

183  Brouardel   (loc.  cit.,  p.  528). 

184  Dumont-Pallier:  Gazette  Hebd.  de  M6d.  et  de  Chir.,  1880,  pp.  374-474. 


134  THE    ACUTE    EXANTHEMATA. 

These  are  all  accompanied  by  slight  itching,  but  no  fever  or  other 
noticeable  symptoms. 

The  writer  has  observed  different  degrees  of  vaccinoid,  or  false 
vaccinia,  in  revaccinating  himself  on  two  or  more  occasions,  and  looks 
upon  it  as  the  vaccinal  eruption  not  infrequently  observed  when  the 
operation  is  repeated  at  frequent  intervals. 

It  is  claimed  that  vaccintia  without  eruption  may  occur.  Thus, 
Treluyer,  with  five  other  physicians  of  Nantes,  in  1825  are  reported 
by  Brouardel  (loc.  cit.,  p.  529)  to  have  vaccinated  60  children  during 
an  epidemic  of  small-pox,  who  developed  the  constitutional  symptoms 
of  vaccinia  without  the  appearance  of  any  lesion  at  the  seat  of  inocula- 
tion. A  second  vaccination  resulted  in  neither  general  nor  local  symp- 
toms. Further,  it  is  claimed  that  in  only  2  did  small-pox  occur,  and 
they  had  not  presented  the  constitutional  symptoms  observed  in  the 
others.  To  further  test  the  protective  influence  thus  acquired  5  chil- 
dren were  inoculated  with  small-pox  with  a  negative  result,  save  a 
slight  indisposition  for  about  a  week.  These  investigators  regard  it 
as  analogous  to  febris  variolosa  sine  variolis  of  Sydenham,  and  the 
scarlatine  fruste  of  Trousseau,  as  well  as  that  occasionally  observed  in 
other  eruptive  fevers  without  the  appearance  of  the  characteristic  ex- 
anthem.  Chauveau  injected  vaccine  virus  subcutaneously  without  pro- 
ducing any  local  manifestations.185 

It  is  quite  possible  that  a  certain  immunity  may  be  acquired  with- 
out the  appearance  of  the  typical  pock,  just  as  a  mother  cannot  be 
inoculated  from  her  chijd  born  syphilitic,  although  she  may  never 
have  had  the  usual  phenomena  of  syphilis.  Such  vaccinations,  how- 
ever, afford  at  best  an  uncertain  protection,  and  it  is  difficult  to  say 
with  any  degree  of  assurance  that  the  constitutional  symptoms  may  not 
be  due  to  extraneous  toxic  substances  which  have  gained  access  to  the 
wound,  rather  than  to  the  specific  effect  of  the  vaccine-virus.  In  such 
cases,  therefore,  revaccination  should  invariably  be  performed. 

SPONTANEOUS  GENERALIZED  VACCINIA  is  another  infrequent  con- 
dition which  has  been  observed.  According  to  Jeanselme,186  this 
eruption  must  not  be  confounded  with  the  general  eruption  due  to 
auto-inoculation.  As  described  by  this  observer,  the  eruption  may  ap- 


185  Chauveau:  "Vaccine  et  Variole"  (Paris,  1865).  "Tentations  d'infection  vaccinale 
par  les  voies  respiratoires  et  par  les  voies  digestives,"  etc.  "Comptes  rendu  de 
1'Acade'mie  des  Sciences,"  1868.  "L'injection  de  lymphe  vaccinale  dans  le  tissue  con- 
jonctif  soucutane."  Bull,  de  1'Acad.  de  M6d.,  1860,  p.  1334. 

184  Jeanselme :  "De  la  Vaccine  generalisee."    Gaz.  des  H6p.,  1892,  p.  253. 


VACCINIA.  135 

pear  simultaneously  with  that  at  the  seat  of  inoculation,  and  consists 
of  lesions  bearing  a  certain  resemblance  to  the  regular  vaccinal  pock. 
More  frequently  they  appear  about  the  seventh  or  eighth  day,  and 
develop  more  rapidly  than  the  initial  sore.  The  eruption  varies  in 
severity  according  to  the  individual  peculiarity  and  may  become  either 
discrete  or  confluent.  In  the  latter  case  death  may  occur.  It  is  said 
to  be  common  after  accidental  inoculation  with  cow-pox  or  horse-pox. 
In  the  writer's  experience,  generalized  vaccinia  has  always  ap- 
peared after  considerable  inflammation  and  suppuration  in  the  original 
vaccinal  pock,  and  the  strong  supposition  has  always  existed  that  pus 
was  conveyed  from  the  primary  sore  by  means  of  the  finger-nails  or 
clothing.  "  It  is  known  that  abrasions  on  the  skin,  such  as  observed  in 
eczematous  or  pruritic  subjects,  predispose  very  strongly  to  general- 
ized vaccinia. 

COMPLICATIONS  AND  SEQUELS. 

Of  great  importance  are  the  concomitant  disturbances  of  vaccina- 
tion, because,  by  proper  attention  on  the  part  of  the  physician  or  those 
responsible  for  the  subsequent  care  of  the  patient,  they  may,  for  the 
most  part,  be  wholly  avoided.  Medical  men  are  often  unjustly  cen- 
sured, while  the  patient  is  to  blame  for  these  attendant  evils.  There 
is,  likewise,  a  tendency  among  the  laity  to  look  upon  vaccination  as 
the  fons  et  origo  of  all  subsequent  ills.  So  loud  was  the  clamor  raised 
in  England  a  few  years  ago  that,  next  to  the  efficacy  of  vaccination  as 
a  protective  agent  against  small-pox,  the  question  second  only  in  im- 
portance with  which  the  Eoyal  Commission  had  to  cope  was  in  refer- 
ence to  the  objections  made  to  vaccination  on  the  ground  of  injurious 
effects  alleged  to  result  therefrom.  It  seems  unnecessary  to  describe 
in  detail  or  even  enumerate  the  various  affections  that  may  be  in- 
oculated at  the  time  of  vaccination  or  be  excited  by  neglect  during 
the  active  period  of  the  vaccinal  eruption.  Xeither  is  it  necessary  to 
discuss  the  various  objections  alleged  against  vaccination,  which  may 
be  found  in  the  "Report  of  the  Royal  Commission,"  to  which  refer- 
ence has  previously  been  made.  If  the  instructions  which  follow  are 
strictly  adhered  to,  the  list  of  'casualties  will  be  exceedingly  short. 
The  most  dire  consequences  may  follow  an  abrasion  or  even  the  prick 
of  a  pin,  if  toxic  substances  gain  access  to  the  wound  either  at  the 
time  of  its  infliction  or  subsequently.  Even  greater  care  should  be 
exercised  in  the  practice  of  vaccination,  and  failure  to  direct,  or  neglect 
in  carrying  out,  the  ordinary  principles  of  antisepsis  should  be  ac- 


136  THE   ACUTE    EXANTHEMATA. 

counted  a  crime.  By  far  the  most  frequent  complications  are  due  to 
the  introduction  of  the  ordinary  pyogenic  micro-organisms. 

Erythema. — Not  infrequently  the  areola  described  as  encircling 
the  normal  vaccinal  pock  extends  far  beyond  the  seat  of  vaccination. 
In  fact,  many  instances  are  recorded  in  which  a  general  roseola  ex- 
tended over  the  entire  body;  more  commonly,  however,  it  is  confined 
to  the  arms,  upper  part  of  the  chest,  and  neck.  Sometimes  the  erup- 
tion bears  a  striking  similarity  to  scarlet  fever  or  measles.  Little  or 
no  constitutional  disturbance  can  be  associated  with  the  appearance  of 
this  exanthem.  It  usually  appears  about  the  ninth  or  eleventh  day, 
and  gradually  fades  in  the  course  of  two  or  three  days.  Various 
theories  have  been  advanced  as  to  the  cause  of  this  eruption,  and  its 
analogy  to  the  medicinal  rashes  has  been  discussed  by  Behrend  and 
Brouardel  (loc.  cit.}. 

Eczema. — In  those  predisposed,  eczema  is  liable  to  appear  about 
the  vaccinal  lesion.  The  irritation  and  consequent  scratching  in- 
dulged in  is  liable  to  set  up  a  vesicular  or  pustular  dermatitis,  which 
may  persist  long  after  the  disappearance  of  the  vaccine  lesion.  Ec- 
zema being  comparatively  common  in  childhood  (the  period  usually 
selected  for  vaccination),  this  complication  deserves  more  than  a  pass- 
ing notice.  That  eczema  may  be  induced  in  those  whose  skins  have 
a  feeble  resistance  to  external  irritants  is  a  well  established  fact. 
Naturally  the  greater  the  irritation,  the  more  liable  is  eczema  to  fol- 
low. Thus,  with  the  development  of  the  vaccinal  lesion  and  its  ac- 
companying inflammation  it  is  not  strange  that  this  complication 
should  assume  the  importance  which  it  occupies.  From  the  records 
of  many  hundred  cases  of  eczema  observed  by  the  writer,  in  not  a 
single  instance  could  the  disease  be  attributed  to  the  influence  of  vac- 
cination alone.  It  has  been  found  in  many  instances  in  which  vac- 
cination was  the  alleged  cause  that  eczema  had  existed  previously,  even 
when  absent  at  the  time  of  vaccination.  On  the  other  hand,  it  has 
often  been  observed  that  eczema  is  intensified  by  vaccination,  and  a 
mild  attack  may  thus  be  changed  into  a  grave,  generalized  eczema. 
Moreover,  greater  danger  exists,  in  subjects  predisposed  either  to 
eczema  or  prurigo,  of  giving  rise  to  a  generalized  vaccinia. 

Generalized  Vaccinia,  Due  to  Auto-inoculation-.  —  It  is  generally 
conceded  that  during  the  first  week  multiple  inoculations  are  possible. 
Cory187  succeeded  in  obtaining  successful  reinoculations  on  successive 


187  Cory  (R.):  "St.  Thomas  Hospital  Reports,"  1885,  vol.  xv,  pp.  101-104. 


VACCINIA.  137 

days  until  the  ninth  day.  The  period  of  greatest  immunity  to  revac- 
cination  is  about  the  fourth  week,  although  there  are  exceptions  to  this 
rule.  Thus,  Allbutt  observed  a  woman  who  had  not  only  had  small- 
pox three  times,  but  had  also  been  three  times  successfully  vac- 
cinated.188 This  explains  the  many  striking  examples  of  generalized 
vaccinia  on  record.  The  eruption  begins  during  the  stage  of  secretion 
or  suppurative  stage  of  the  pock,  and  is  usually  the  result  of  scratch- 
ing or  otherwise  rupturing  the  original  lesion.  The  virus  may  then 
be  conveyed  to  denuded  parts  by  the  clothing,  or  more  commonly 
directly  by  the  finger-nails,  as  in  the  act  of  scratching.  In  the  case 
recorded  by  Acland  (loc.  cit.,  p.  576)  the  eruption  appeared  on  the 
face,  arms,  legs,  abdomen,  and  thighs,  assuming  in  places  a  confluent 
form,  which  resulted  in  the  formation  of  large,  open  sores,  and  ter- 
minated fatally  in  the  eighth  week.  More  frequently  the  eyelids,  nose, 
lips,  or  anal  region  are  involved.189  The  lesions,  therefore,  vary  from 
one  or  two  to  several  hundred,  and,  in  appearance,  bear  a  striking 
resemblance  to  the  original  vaccinal  sore,  excepting  that  they  often 
mature  more  rapidly  and  are  prone  to  become  pustular  at  a  very  early 
stage.  The  constitutional  symptoms  are  generally  well  marked,  al- 
though naturally  they  are  largely  dependent  on  the  number  and  ex- 
tent of  the  lesions.  The  striking  and  wide-spread  appearance  of  this 
eruption  gives  rise  to  some  difficulty  in  diagnosis.  One  should  there- 
fore bear  in  mind  the  possibility  of  autoinoculation  in  all  cases  of 
supernumerary  pocks.  In  one  instance  of  generalized  vaccinia  thus 
produced,  which  came  under  the  writer's  observation,  not  only  were 
the  constitutional  symptoms  severe,  but  the  close  resemblance  to 
variola  was  a  striking  feature.  The  duration  of  the  individual  pocks, 
however,  is  shorter,  and,  when  one  is  able  to  watch  the  method  of 
extension  and  development  of  the  eruption,  its  true  nature  may  readily 
be  ascertained. 

Papillary  hypertrophy.,  commonly  called  red-raspberry  excrescence, 
is  occasionally  encountered.  It  usually  begins  to  develop  a  few  days 
after  the  insertion  of  the  lymph,  in  the  form  of  a  red  papule  which 
increases  in  size,  varying  from  that  of  a  pea  to  a  pigeon's  egg.  It  some- 
times remains  several  months,  then  gradually  disappears.  It  is  met, 
for  the  most  part,  in  strumous  subjects.  The  inmates  of  hospitals 


188  Acland  (T.  D.):  See  "Vaccinia  in  Man,"  in  Allbutt's  "System  of  Med."   (New 
York,  1897),  vol.  iii,  p.  576. 

189  Pelkin  (R.  W.):  "Edinburgh  Obstet.  Trans.,"  vol.  xvi,  p.  807. 


138  THE   ACUTE    EXANTHEMATA. 

seem  especially  prone  to  this  anomaly,  as  was  observed  recently  in  vac- 
cinating the  inmates  of  Lakeside  Hospital. 

Vaccinia  Hcemorrliagica. — Cases  of  vaccinia  haemorrhagica  are 
recorded  by  Gregory,  Bergeron,  and  Barthelemy  (Acland,  loc.  cit.,  p. 
578).  They  are  met  with  in  scorbutic  or  rachitic  children,  in  whom 
the  power  of  resistance  is  low.  The  haemorrhage  may  be  limited  to 
the  vaccine  pustule,  or  more  or  less  extensive  areas  may  be  covered 
with  small,  pin-head-sized  petechiae  or  subcutaneous  ecchymoses.  This 
complication,  like  many  others,  is  probably  wholly  dependent  on  the 
general  condition  of  the  patient,  and  care  should  be  taken  in  placing 
the  recipient  for  vaccination  in  the  best  possible  physical  condition. 

Erysipelas. — This  is  a  danger  incident  to  "all  open  wounds  or 
abrasions  of  the  surface  from  whatsoever  cause,  and  is,  therefore,  not 
peculiar  to  vaccination.  According  to  the  last  "Census  Report  of  the 
United  States,"  the  average  death-rate  from  erysipelas  to  every  100,000 
inhabitants,  of  all  ages,  was  16.47,  while  under  five  years  of  age  it 
was  31.34:  per  100,000.  In  a  series  of  100  cases  of  erysipelas  Allen190 
found  the  point  of  infection  in  50  per  cent,  to  be  some  defect  or  abra- 
sion of  the  skin.  It  is  further  known  that  erysipelas  is  especially  com- 
mon among  the  uncleanly.  Thus,  according  to  the  "Louisville  Health 
Reports,"191  of  the  79  deaths  from  erysipelas  during  the  past  ten  years, 
17  were  in  the  colored  race.  As  strong  predisposing  causes  of  ery- 
sipelas we  have,  therefore,  age  (under  five  years),  an  abrasion  or 
wound  of  the  skin,  and  uncleanly  habits,  all  of  which  are  furnished 
to  a  greater  or  lesser  degree  in  the  great  majority  of  recipients  of  vac- 
cination. 

Further,  erysipelas  is  now  known  to  be  due  to  a  specific  micro- 
organism, the  streptococcus  erysipelatosus  of  Fehleisen,  which  develops 
most  readily  in  an  irritated  vaccinal  lesion.  As  shown  by  Pfeiffer,192 
Crookshank,193  Sternberg,194  Landmann,195  and  others,  vaccine  lymph 
may  contain,  among  various  other  micro-organisms,  streptococci  ca- 
pable of  producing  erysipelas,  although  they  are  extraneous  or  acci- 
dental constituents;  for  the  same  observers  have  likewise  shown  that 
vaccine  lymph  which  has  been  deprived  of  all  known  living  pyogenic 

190  Allen  (C.  W.):  Medical  News,  April  8,  1899. 

191  Quoted  by  H.  W.  Stelwagon:   "Diseases  of  the  Skin,"  in  "Prog.   Med.,"   1899, 
vol.  Hi,  p.  191. 

182  Pfeiffer  (E.):  Internat.  klin.  Rund.,  1889,  p.  72. 

198  Crookshank  (E.  M.):  Evidence  given  to  the  Royal  Commission,  and  "The  His- 
tory and  Pathology  of  Vaccination"  (London,  1887),  vol.  i. 

194  Sternberg  (G.):   Med.   Record  (New  York,  1896),  p.  677. 

196  Landmann:  Hygienische  Rund.,  1895,  p.  976,  and  1896,  p.  441. 


VACCINIA.  139 

organisms  still  gives  rise  to  the  characteristic  effects  of  vaccination. 
Finally,  Kitasato's196  experiments  go  to  prove  that  all  inflammatory 
symptoms  connected  with  vaccination  are  due  to  the  presence  of 
extraneous  pathogenic  organisms  in  the  lymph. 

It  is  clear  from  the  foregoing  that  erysipelas,  although  common, 
is  one  of  the  preventable  complications  of  vaccination,  and  may  be 
avoided  by  using  pure  or  sterilized  lymph,  and  by  excluding  pathogenic 
germs  from  the  wound. 

Ukeration,  Glandular  Abscess,  Septic  Infection,  Gangrene,  and 
Tetanus. — When  one  considers  the  gross  ignorance  displayed  by  some 
in  performing  the  operation  of  vaccination  the  wonder  is  that  pre- 
ventable complications  and  sequelae  are  not  even  more  frequently  met 
with  than  statistics  show  them  to  be.  It  is  to  be  hoped  that,  with  a 
more  general  understanding  of  antiseptic  principles,  or  at  least  the 
importance  of  cleanliness  in  all  procedures  in  which  the  natural  bar- 
riers to  disease  are  removed,  the  conditions  herein  mentioned  will  be- 
come unknown.  Much  has  been  accomplished  in  this  direction  since 
the  methods  once  in  vogue,  as  portrayed  by  Creighton,197  were  in  gen- 
eral use,  as  well  as  those  practiced  in  the  rural  districts  of  America 
even  in  the  writer's  boyhood.  Fortunately,  it  is  no  longer  the  custom 
to  vaccinate  from  arm  to  arm  without  the  services  of  a  physician,  and 
they  no  longer  carry  the  vaccinal  crust  loosely  in  the  vest-pocket. 
Little  wonder  that  the  small  boy,  with  an  intuition  wiser  than  he 
knew,  ran  to  the  woods  to  escape  the  much-dreaded  "sore  arm."  Yet 
it  is  not  in  the  rural  districts  that  the  frightful  consequences  herein 
mentioned  are  most  frequently  observed.  In  the  poor  districts  of 
cities  and  in  asylums  where  the  standard  of  health  is  reduced  to  a 
low  ebb  these  complications  are  most  common.  Upon  the  condition 
of  the  tissues,  therefore,  and  their  variable  resisting  power  depend 
mainly  the  phlegmonous  and  ulcerative  changes  described,  although 
the  exciting  cause,  as  previously  stated,  depends  Upon  the  presence  of 
extraneous  excitants  not  necessarily  associated  with  vaccination. 
Formerly,  when  humanized  lymph  was  used  more  generally  than  at 
present,  septicaemia  due  to  contaminated  lymph  was  more  common. 
Pincus  found  evidences  of  decomposition  and  septic  bacteria  in  the 
lymph  employed  at  Crabnick  in  1878,  when,  of  50  children  vaccinated, 
several  had  an  erythematous  eruption,  others  phlegmonous  swellings 


19«Kitasato:  Sei-i-Kwai  Med.  Jour.   (Tokyo),  1896,  pp.  91  and  176. 
197  Creighton :  "The  Natural  History  of  Cow-pox  and  Vaccinal  Syphilis"  (London, 
1887). 


140  THE   ACUTE    EXANTHEMATA. 

and  abscesses,  and  15  died.198  Brouardel  (loc.  cit.,  p.  534)  gives  in 
detail  an  account  of  the  appalling  results  following  the  use  of  vitiated 
virus  at  Asprieres,  in  1885.  Of  42  children  vaccinated,  6  died  within 
twenty-four  hours,  and  many  others  were  dangerously  ill.  Investiga- 
tion showed  that  the  lymph  used  had  gradually  developed  virulent 
properties  by  successive  inoculations  in  the  human  subject,  until  the 
fifth  cultivation  gave  rise  to  all  the  clinical  phenomena  of  septicasmia. 
It  is  obvious,  therefore,  that  great  care  should  be  taken  in  selecting  the 
virus,  and,  when  possible,  only  the  sterilized  lymph  derived  from  the 
calf  should  be  employed.  Humanized  lymph  should  never  be  used 
unless  the  preceding  cultures  have  been  under  the  care  of  a  competent 
observer. 

Impetigo  sometimes  follows  vaccination,  appearing  about  the  end 
of  the  third  week.  It  should,  therefore,  be  regarded  as  a  sequela  rather 
than  a  complication.  In  the  cases  that  have  come  under  the  writer's 
observation  it  has  seemed  to  proceed  originally  from  suppuration  and 
copious  pus  formation  in  the  original  lesion,  with  the  subsequent  de- 
velopment of  multiple  suppurative  foci  in  the  immediate  neighbor- 
hood. According  to  Payne,199  pus  micro-organisms  increase  in  viru- 
lence by  being  cultivated  in  a  focus  of  local  inflammation,  by  having 
an  abundant  supply  of  oxygen,  and  by  inoculating  them  from  one  in- 
dividual to  another.  He  has  further  observed  that  a  series  of  such 
successive  inoculations,  especially  if  rapid,  appears  to  markedly  in- 
crease the  virulence  of  most  contagions.  For  this  reason  the  local 
inflammation  accompanying  vaccinia  when  aseptic  precautions  are 
disregarded,  gives  rise  to  micro-organisms  which,  when  inoculated 
successively  from  place  to  place  on  the  body,  or  from  individual  to 
individual,  as  is  not  uncommon  in  crowded  dwellings,  develops  viru- 
lent properties  which  result  in  sero-purulent  lesions,  which  spread 
rapidly,  both  at  the  periphery  and  from  place  to  place,  until  the  whole 
cutaneous  surface  is  more  or  less  involved.  Some  of  the  severest  con- 
comitants, or  more  correctly  sequelae,  of  vaccination  are  those  of  gen- 
eralized bullous  dermatitis.  (Plates  XXI  and  XXII.)  Bowen200  has 
reported  five  cases  of  bullous  dermatitis  which  appeared  from  one  to 
four  weeks  after  vaccination.  In  these  cases  the  localization  of  the 
lesions  was  a  conspicuous  feature,  it  having  a  marked  tendency  to 

188Pincus:  "Die  Impfung  in  Crabnick."  Vierteljahresschrift  fur  Gerichtl.  Med., 
etc.,  July,  1879. 

188  Payne:  The  Lancet,  July  4,  1896. 

200  Bowen  (J.  T.):  "Trans,  of  the  Amer.  Derm.  Assoc.,"  1900;  also  in  Jour.  Cut. 
and  Genito-Urin.  Dis.  (New  York),  August,  1900,  p.  344. 


PLATE  XXL 


X 
X 


PLATE  XXII. 


PLATE  XXII. 


Same   as  the    Preceding,    showing   Feet   and   Ankles. 


VACCINIA.  141 

group  about  the  mouth,  chin,  nose,  and  ears,  and  upon  the  backs  of 
the  hands  and  feet.  In  addition,  the  extensor  aspects  of  the  extremi- 
ties were,  in  general,  more  prominently  affected,  while  the  trunk  was 
but  slightly  affected  as  compared  with  other  regions  of  the  body.  Such 
cases  are  liable  to  be  confounded  with  pemphigus.  It  has  been  the 
writer's  fortune,  as  well  as  misfortune,  to  be  called  upon  to  decide 
between  the  medical  attendant  and  the  patient's  family  relative  to 
placing  the  responsibility  in  cases  of  what  seemed  to  be  the  bullous 
variety  of  impetigo.  When  sterilized  virus  has  been  used,  the  parts 
properly  prepared,  and  suitable  instructions  given  as  to  the  proper  care 
of  the  case,  with  the  request  that  he  be  allowed  to  inspect  the  patient 
once  or  twice  thereafter  during  the  first  week,  the  medical  attendant's 
responsibility  ceases. 

Psoriasis. — The  cause  of  psoriasis  is  unknown,  but  certain  ob- 
servations concerning  its  appearance  lead  one  to  believe  that  there  is 
an  underlying  condition  that  predisposes  to  or  offers  a  suitable  soil 
for  the  development  of  the  disease.  We  know,  further,  that  in  cer- 
tain persons  the  skin  exposed  to  the  pressure  and  friction  of  suspenders, 
skirt-bands,  hat-bands,  and  garters  becomes  the  primary  seat  of  the 
psoriatic  eruption.  In  fact,  it  may  remain  well-nigh  limited  to  these 
parts.  It  is  a  matter  of  common  observation  that  psoriasis  usually  first 
appears,  and  is  the  most  persistent,  on  the  tips  of  the  elbows  and  knees: 
parts  most  exposed  to  the  constant  irritation  of  the  clothing.  Further- 
more, it  is  not  unusual  to  hear  psoriatic  patients  say  that  at  the  onset  of 
an  attack  every  scratch  or  abrasion  inflicted  on  the  sound  skin  gives 
rise  to  a  psoriatic  patch.  With  these  observations  before  us  it  is  not 
surprising  that  occasionally  psoriasis  appears  after  vaccination.  In  two 
cases  of  psoriasis  during  the  past  year  the  cause  assigned  by  the  family 
was  vaccination,  because  the  eruption  first  made  its  appearance  at  that 
time.  A  moment's  consideration  will  enable  one  to  appreciate  the 
etiological  influence  of  vaccination  in  psoriasis,  because  we  know  that 
pressure,  friction,  irritation,  or  vaccination  will  not  of  themselves  give 
rise  to  the  disease.  However  strongly  these  determining  or  exciting 
influences  may  appear  to  be  the  real  cause,  there  still  remains  an 
essential  something  of  which  we  are  at  present  ignorant. 

Tuberculosis. — The  experiments  made  by  Besnier,201  Bellinger,202 


201  Besnier  (E.):   "Lupus  Vaccinal,"  Ann.  de  Derm,  et  de  Syph.,  1889,  p.  576. 

202  Bellinger:    "Ueber    die    Infectionswege    des    tuberculosen    Giftes."      Miinchener 
med.  Woch.,  1899,   p.  567. 


142  THE   ACUTE    EXANTHEMATA. 

and  Strauss203  leave  us  in  doubt  as  to  the  possibility  of  inoculating  the 
tubercle  bacillus  in  the  process  of  vaccination.  From  clinical  observa- 
tion204 it  seems  highly  probable  that  tuberculosis  may  be  inoculated  in 
the  skin;  at  the  same  time,  it  is  only  possible  when  the  tissues  furnish 
a  favorable  culture-medium,  such  as  is  observed  in  struma  and  other 
debilitated  conditions.  The  clinical  forms  of  tuberculosis  vary  in  dif- 
ferent cases;  in  strumous  children,  indolent,  phlegmonous  swellings, 
abscesses,  and  ulcers  are  sometimes  met  with.  Talcott  Fox  and  Acland 
have  observed  lupus  vulgaris  develop  in  vaccination  scars  (Acland,  loc. 
cit.,  p.  622),  although  in  neither  instance  was  the  source  of  the  affec- 
tion known.  Xo  proof,  therefore,  exists  that  lupus  attacks  vaccination 
scars  more  frequently  than  it  does  those  resulting  from  other  causes. 
Moreover,  it  is  of  great  importance  that  the  subject  for  vaccination  be 
placed  in  the  best  possible  health,  and  especially  does  this  apply  to 
those  who  are  predisposed  to  tuberculosis:  a  condition  commonly  de- 
nominated scrofula. 

Syphilis. — Much  has  been  written  on  the  subject  of  syphilis  due 
to  vaccination,  and  without  question  it  is  a  sequela  against  which  the 
medical  man  should  constantly  be  on  guard.  Formerly  when  human- 
ized lymph  was  used  it  was  a  far  greater  source  of  danger  than  it  is 
now.  No  one  who  has  had  much  to  do  with  syphilis  pretends  to  be 
able  to  select  from  a  group  of  children  in  any  public  establishment 
those  free  from  syphilis,  yet  the  writer  was  so  taught  and  expected  to 
do  in  an  East  London  vaccination  station  twenty  years  ago.  It  is 
true  that  cases  of  syphilis  even  then  were  rarely  indeed  encountered, 
and  the  writer  has  never  observed  syphilis  thus  contracted.  Only  by 
the  strictest  care,  however,  can  this  be  obviated  with  the  system  of 
arm-to-arm  vaccination  or  in  selecting  lymph  as  herein  mentioned. 
It  is  well  known  that  blood  from  a  syphilitic  source  will  give  rise  to 
syphilis  when  inoculated  into  a  non-syphilitic  subject,  but  it  is  not 
positively  known  that  the  disease  can  be  communicated  by  injecting 
the  clear  vaccine  lymph  obtained  from  a  person,  even  when  contami- 
nated with  syphilis.  On  the  contrary,  the  experiments  of  Husson, 
Bousquet,  and  Steinbrenner  (quoted  by  Brouardel,  loc.  cit.,  p.  538) 
prove  that  lymph  taken  from  a  syphilitic  subject  may  be  inoculated 
in  a  susceptible  person  without  communicating  syphilis,  while  Vien- 


208  Strauss:  "La  tuberculose,  est  elle  transmissible  par  le  vaccin?"  Soc.  Med.  des 
H6p.,  February  13,  1885. 

204  The  author:  "Lupus  Vulgaris  following  Exposure  to  Tuberculous  Sputa." 
Jour.  Cut.  and  Genito-Urin.  Dis.  (New  York),  April,  1893. 


VACCINIA.  143 

nois205  demonstrated  conclusively  that  syphilis  may  be  transmitted  by 
vaccination.  Brouardel  (loc.  cit.,  p.  541)  describes  an  epidemic  of  syph- 
ilis due  to  vaccination  which  occurred  at  Rioalta  in  1861,  in  which 
virus  from  a  syphilitic  child  was  used  in  vaccinating  46  healthy  chil- 
dren. One  of  these  children  served  as  vaccinifer  for  17  other  children, 
making  63  in  all,  of  whom  46  were  infected  with  syphilis:  39  of  the 
first  series  and  7  of  the  second. 

Moreover,  it  is  difficult  to  arrive  at  a  correct  conclusion  on  the 
subject  of  invaccinated  syphilis.  Many  cases  thus  reported  rest  on 
doubtful  evidence,  while  others  are  reported  from  hearsay  alone.  This 
was  clearly  pointed  out  in  the  investigations  of  the  Eoyal  Commission, 
which  found  that  of  all  cases  of  syphilis  alleged  to  be  due  to  vaccina- 
tion occurring  between  the  years  1889  and  1896,  when  subject  to  a 
searching  inquiry,  not  one  could  be  proved  to  be  syphilis.  During 
this  time  the  whole  number  of  vaccinations  in  Great  Britain  approxi- 
mated six  millions.  The  experiments  made  by  Cory206  on  himself  are 
instructive  in  this  connection.  This  investigator  purposely  vaccinated 
himself  with  lymph  taken  from  a  syphilitic  child.  The  vaccination 
was  unsuccessful,  the  lesions  maturing  early  and  falling  off  about  the 
fourth  or  fifth  day.  No  evidence  of  syphilis  followed.  About  two 
years  later  he  again  vaccinated  himself  with  lymph  taken  from  a  pa- 
tient known  to  be  syphilitic,  with  a  negative  result  both  as  to  the  syph- 
ilis and  vaccinia.  The  experiment  was  again  made  about  eighteen 
months  later  with  a  like  result.  In  the  fourth  experiment  the  lymph 
was  taken  from  a  child  contaminated  with  congenital  syphilis.  The 
common  symptoms  of  congenital  syphilis,  such  as  snuffles,  thrush,  etc., 
had  been  observed,  and  there  was  still  present  a  cutaneous  syphilitic 
eruption.  No  syphilitic  lesions  were  situated  in  the  vicinity  of  the 
vaccine-vesicles,  which  were  normal  in  appearance  and  not  inflamed. 
They  were  shallow  and  difficult  to  open  without  drawing  blood,  al- 
though the  utmost  care  was  taken  that  no  admixture  of  blood  should 
take  place,  and  the  lymph  was  collected  on  a  clean  instrument.  Three 
insertions  were  made,  and  aside  from  an  erythema  which  disappeared  in 
about  a  week,  they  presented  no  unusual  symptoms.  On  the  twenty- 
first  day,  however,  there  appeared  a  slight  disturbance  in  two  of  the 
points  of  inoculation,  one  of  which  developed  into  a  typical  chancre 


20BViennois:  "Transmission  de  la  Syphilis  par  la  Vaccination."     Archiv.  G6n.  de 
M6d.,  July,  1860. 

206  Cory  (R.):  "Report  of  the  Royal  Commission,"  p.  244. 


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VACCINIA.  145 

From  the  foregoing  it  is  clear  that  exaggerated  reports  relative 
to  the  frequency  of  syphilitic  invaccination  have,  from  time  to  time, 
been  made,  and  it  must  be  acknowledged  that  its  occurrence  is  one  of 
great  infrequency.  When  bovine  virus  is  employed,  the  possible  in- 
fection of  syphilis  need  not  be  taken  into  consideration. 

Leprosy. — In  countries  where  leprosy  prevails  the  possibility  of 
communicating  the  disease  by  vaccination  must  be  considered.  Much 
that  has  been  said  of  syphilis  applies,  although  in  a  less  degree,  to 
leprosy.  Thus  far  attempts  to  inoculate  leprosy  in  non-leprous  sub- 
jects have  failed.  A  Xorwegian  physician,210  about  forty  years  ago, 
attempted  to  communicate  leprosy,  both  to  himself  and  others,  by  in- 
troducing under  the  skin  leprous  tubercles,  blood  and  pus,  with  a 
negative  result.  Profeta211  failed  in  like  manner,  as  did  Cagnina.212 
Kobner213  and  Hansen214  failed  to  inoculate  monkeys,  as  have 
Kaurin,215  Rake/16  and  others. 

To  ascertain  the  possibility  of  transmitting  leprosy  by  vaccina- 
tion Bevan  Rake  and  Buckmaster217  vaccinated  eighty-seven  lepers  in 
the  Almora  Asylum  at  Trinidad.  Their  report  may  be  given  in  full 
as  follows: — 

"Of  the  87  vaccinated,  40 — 21  males  and  19.  females — developed 
vesicles,  which  were  examined. 

"Of  the  40  cases, 

34  were  anaesthetic. 
5  were  mixed. 
1  was  tuberculated. 

"The  condition  of  the  skin  where  vaccinated  was  as  follows: — 
In  14  cases  it  was  normal. 
In  13  cases  there  was  an  anaesthetic  patch. 
In  12  cases  sensation  was  diminished. 
In     1  case  there  was  tuberculation. 


210  "Appendix  1,  Report  of  Leprosy  Commission"  (London,  1893),  pp.  432  et  seq. 

211  Profeta:  "Sur  1'Elephantiasis  des  Grecs."    Giorn.  intern,  dell.  Sci.  Med.,  1884. 

212  Cagnina:  Quoted  by  Leloir:  "Traite  Practique  et  Theorique  de  la  Lepre"  (Paris, 
1886). 

213  Kobner:  Virchow's  Archiv,  1882,  vol.  xxxviii,  p.  282. 

214  Hansen :   Congress  Med.  de  Copenhague,  1884,  Comptes  rendu. 

215  Kaurin:  Jour,  of  the  Leprosy  Invest.  Com.,  No.  2,  1891,  p.  68. 

216  Rake  (B.):  "Reports  of  Trinidad  Leper  Asylum,"  1884  to  1889. 

217  Rake    (B.)   and   Buckmaster   (G.   A.):    "An   Inquiry  into  the  Question  of  Com- 
municability  of  Leprosy  by  Vaccination."    Jour,  of  the  Leprosy  Invest.   Com.   (London), 
1891,  No.  4,  pp.  33  and  34. 

10 


146  THE   ACUTE    EXANTHEMATA. 

"The  condition  of  the  vesicles  was  as  follows: — 

In  31  cases  normal. 

In     2  cases  purulent. 

In     2  cases  purulent  and  mixed  with  blood. 

In     1  case  normal  on  the  one  arm  and  purulent  on  the  other. 

In     1  case  normal,  but  mixed  with  blood  in  taking. 

In     1  case  immature. 

In     1  case  immature  and  mixed  with  blood  in  taking. 

In     1  ease  immature  and  the  crust  taken. 

"Crusts  also  were  taken  from  two  vesicles  which  had  been  normal. 

"Ninety-three  cover-glasses  were  prepared,  and  in  no  case  were 
undoubted  leprous  bacilli  found.  Suspicious  looking  rods  taking 
fuchsin  were  seen  in  1  case  in  vesicles  raised  over  tuberculated  areas, 
and  in  another  case  in  vesicles  over  anaesthetic  patches.  Even  if  one 
were  to  consider  these  cases  positive,  and  give  them  their  utmost 
value,  they  would  have  little  or  no  bearing  on  the  question  at  issue, 
for  no  vaccinator  would  be  likely  to  vaccinate  a  leper  over  a  tubercle 
or  anaesthetic  patch,  and  use  the  lymph  obtained  from  such  vesicles 
for  vaccinating  healthy  individuals. 

"It  is,  therefore,  the  opinion  of  the  writers  that,  assuming  the 
presence  of  bacilli  to  be  necessary  to  produce  leprosy,  this  series  of  ob- 
servations— the  most  extensive  yet  made — goes  to  show  that  no  dan- 
ger need  be  apprehended  from  the  vaccine  lymph  or  even  an  actual 
leper,  provided  he  is  vaccinated  on  apparently  normal  skin.  A  fortiori, 
therefore,  there  is  no  danger  of  transmitting  leprosy  by  using  as  a 
vaccinifer  a  child  born  of  a  family  in  which  leprosy  exists/' 

From  the  foregoing  it  may  be  readily  inferred  that  there  exists 
only  a  remote  probability  of  communicating  leprosy  from  a  vaccinifer 
to  a  vaccinee;  no  physician  would,  however,  think  of  obtaining  lymph 
from  such  a  source.  Until  further  light  is  obtained  on  the  propaga- 
tion of  leprosy  it  is  advisable  in  leprous  countries  to  use  vaccine  lymph 
from  the  calf,  or,  at  least,  that  obtained  in  non-leprous  countries. 

Viewing  the  complications  and  sequelae  of  vaccination  as  a  whole, 
we  are  forced  to  admit  that  an  infinitesimally  small  number  are  to  be 
looked  upon  as  unavoidable,  and  necessarily  connected  with  the  prac- 
tice of  vaccination.  Most  of  the  diseases  alleged  to  be  invaccinated 
are  really  introduced  by  extraneous  circumstances,  or  are  the  result 
of  a  natural  tendency  or  constitution  rather  than  from  any  inherent 
property  of  the  vaccine  virus.  To  more  forcibly  illustrate  what  may 


VACCINIA.  147 

be  reasonably  expected  with  approved  modern  methods  of  vaccination 
the  experience  of  Voigt,218  of  Hamburg,  may  be  cited.  In  100,000 
vaccinations  performed  during  the  past  five  years  there  occurred  1 
case  of  axillary  abscess  and  2  others,  the  locality  not  given;  1  of 
furunculosis;  2  of  erysipelas,  and  5  vaccinal  ulcerations,  with  1  death 
(Acland,  loc.  cit.,  p.  600).  With  the  plentiful  supply  of  sterilized  lymph 
prepared  under  strict  aseptic  conditions,  taken  directly  from  the  calf, 
there  is  no  reason  why  Voigt's  results  may  not  be  more  generally  ob- 
tained. 

VACCINE  VIKUS:    ITS  SELECTION  AND  PKESEKVATION. 

Humanized  lymph,  either  for  immediate  or  future  use,  should  be 
selected  from  healthy  children  whose  antecedents  are  known,  and  who 
present  a  typical,  normal,  primary  vaccine  vesicle,  having  translucent 
or  slightly  opalescent  contents.  As  previously  stated,  this  is  usually 
met  with  about  the  seventh  or  eighth  day.  Unduly  severe  or  inflamed 
pustules  should  be  rejected.  The  lymph  should,  for  the  same  reason, 
be  drawn  before  the  formation  of  the  areola.  The  age  most  desirable 
varies  from  six  months  to  eight  or  ten  years.  No  one  should  be  in- 
trusted in  procuring  lymph  who  is  not  thoroughly  familiar  with  the 
principles  of  asepsis  and  appreciates,  in  a  high  degree,  the  essential 
habit  of  cleanliness.  Therefore  all  instruments  and  appliances  should 
be  sterilized  by  heat,  carbolic  acid,  absolute  alcohol,  or  some  other 
potent  germ-destroyer.  After  being  thus  treated  they  should  be  rinsed 
in  sterilized  water  and  dried.  Before  opening  the  vaccine  vesicle  the 
parts  should  be  carefully  cleansed  by  means  of  a  boric-acid  solution 
or  other  mild  antiseptic,  which  should  be  followed  immediately  by 
copious  flushing  with  sterilized  water.  This  latter  is  important,  as  the 
lymph  is  rendered  inert  by  contact  with  even  a  mild  solution.  If  these 
precautions  are  not  carried  out,  pathogenic  organisms  are  liable  to  gain 
access  to  the  lymph  collected,  rendering  it  liable  to  result,  when  used, 
in  a  mixed  infection.  The  best  receptacle  is  a  fine  glass  tube,  not 
more  than  a  twenty-fourth  of  an  inch  (1  millimetre)  in  diameter  and 
about  two  and  a  half  inches  (6  centimetres)  in  length.  An  opening  is 
made  in  the  upper  third  of  the  vesicle  by  a  lancet  and  one  end  of  the 
tube  inserted.  The  lymph  flows  in  by  capillary  attraction,  and  when 
about  two-thirds  full  the  ends  are  hermetically  sealed  by  holding  them 
for  a  moment  in  the  flame  of  a  spirit-lamp  or  Bunsen  burner.  The 

218  Voigt:  "Ueber  Impfschaden."    Wiener  med.  Presse,  1895. 


148  THE   ACUTE    EXANTHEMATA. 

empty  end  should  first  be  thrust  in  the  flame  which  forms  a  vacuum, 
drawing  the  contained  lymph  away  from  the  opposite  end,  which  may 
then  be  sealed,  without  injuring  the  lymph,  by  heat.  Several  punct- 
ures may  be  necessary  to  evacuate  the  contents  of  the  vesicle,  but  care 
should  be  taken  that  the  base  of  the  pock  is  not  disturbed,  lest  blood 
be  mixed  with  the  lymph.  No  harm  can  come  from  healthy  blood- 
cells,  but,  as  previously  shown,  there  is  sometimes  a  possibility  of  their 
harboring  pathogenic  organisms,  especially  syphilis.  The  tubes  should 
then  be  kept  in  a  cool,  dark  place  for  future  use.  Formerly  the  virus 
was  preserved  by  dipping  lancet-shaped  points  of  ivory,  bone,  or  cellu- 
loid into  the  lymph  and  allowing  them  to  dry.  The  danger  of  their 
becoming  septic  and  their  more  rapid  deterioration  has  caused  them  to 
be  well-nigh  discarded.  Preserving  the  crust  as  it  becomes  detached, 
likewise  in  vogue  at  one  time  and  still  sometimes  in  use  among  the 
laity,  cannot  be  recommended  for  the  same  reason.  It  is  claimed  that 
it  retains  the  active  principle  longer  than  other  forms.  Humanized 
virus,  once  thought  to  be  less  severe  and  more  certain  of  resulting  in^ 
a  successful  vaccination,  is  now  used  only  in  emergencies  when  bovine 
lymph  cannot  be  obtained.  It  deteriorates  most  rapidly  when  exposed 
to  the  light,  and  in  a  temperature  above  70°  F.  (21.1°  C.). 

Bovine  Lymph. — At  the  beginning  of  the  nineteenth  century  pub- 
lic opinion  was  not  prepared  for  bovine  vaccination,  and  the  most  sense- 
less, though  ludicrous,  notions  as  to  its  effects  were  entertained  by  the 
people.  (Plate  XXIV.)  Hence,  arm-to-arm  vaccination  became  gen- 
erally practiced.  Not  so  in  Italy,  where  Troja,  of  Naples,  regarding 
vaccinia  as  an  affection  natural  to  the  human  race,  deteriorated  in  sin  - 
cessive  cultures,  inoculated  heifers  in  1804  in  order  to  maintain  a 
supply  of  efficient  vaccine  virus.  Four  years  later  Galbiata,219  a  stu- 
dent of  Troja,  advocated  bovine  lymph  because  it  possessed  a  more 
decided  action  without  greater  danger,  and  was  in  no  way  less  pro- 
tective than  humanized  virus.  He  further  maintained  that  it  offers 
an  advantage  in  that  no  other  disease  can  be  communicated  thereby. 
According  to  Brouardel  (loc.  cit.,  p.  546),  animal  vaccination  in  Paris 
was  first  proposed  by  James,  although  it  met  with  little  encourage- 
ment. The  rapid  strides  made  in  bacteriology,  however,  during  the 
last  decade  or  two,  have  enabled  us  to  eliminate  many  hitherto  unsus- 
pected sources  of  disease,  and  accordingly  animal  or  bovine  vaccine 
virus  has  lost  its  former  terrors.  As  prepared  to-day  at  several  well 

219  Galbiati  (G.):  "Memoria  sulla  inoculazione  collumore  ricavato  immediatamente 
della  vacca  precedentemente  inoculata"  (Naples,  1810). 


I'LATK  XXIV. 


' 


The   Cow-pox,   or  the   Wonderful    Effects   of  the    New    Inoculation."      Distributed    by 

the  Antivaccine   Society  of   London.      (From   an   Old    Print 

in   the   Author's   Collection.) 


VACCINIA.  149 

appointed  establishments  for  the  propagation  and  collection  of  vac- 
cine lymph  in  the  United  States,  animal  virus  is  not  only  as  mild,  but 
equally  as  sure  of  "taking,"  as  that  of  one  or  more  removes  in  the 
human  subject. 

For  many  years  bovine  lymph  preserved  in  glycerin  has  been  in 
general  use  in  Germany  and  Belgium.  Chambou,  Menard,  and 
Strauss220  first  demonstrated  the  sterilizing  effect  of  glycerin.  To  the 
latter,  especially,  we  are  indebted  for  a  series  of  carefully  conducted 
experiments,  in  which  it  was  shown  that  cultures  made  from  fresh 
lymph,  either  alone  or  mixed  with  glycerin,  gave  rise  to  colonies  of 
various  microbes,  such  as  the  staphylococcus  pyogenes  aureus  and  albus, 
while  lymph  mixed  with  glycerin  and  allowed  to  remain  ten  days  con- 
tained fewer;  and,  at  the  end  of  fifty  or  sixty  days,  cultures  showed 
the  virus  to  be  sterile.  This  proved  conclusively  that  glycerin  was  not 
only  a  convenient  vehicle  in  which  to  preserve  vaccine  lymph,  but  of 
great  importance  in  rendering  it  sterile  without  impairing  its  specific 
virus.  This  was  supposed  to  be  due  to  its  effect  in  preventing  putre- 
faction of  the  organic  substances  contained  in  the  lymph,  thus  de- 
stroying the  ordinary  saprophytes,  while  the  essential  principle,  or 
virus,  was  preserved.  Other  observers- — among  whom  may  be  men- 
tioned Klein,221  Leoni,222  and  Kinyoun223 — have  confirmed  these  ob- 
servations, and  further  demonstrated  that  other  pathogenic  micro- 
organisms, such  as  the  tubercle  bacillus  and  the  streptococcus  of  ery- 
sipelas, may  be  destroyed  in  like  manner  when  exposed  a  few  weeks 
to  the  action  of  glycerin.  In  this  country  bovine  lymph  has  gradually 
come  into  general  use,  and  is  now  the  only  recognized  commercial 
form.  In  cultivating  and  collecting  it  the  same  careful  procedures 
previously  described  are  necessary.  Specially  prepared  stables,  ren- 
dered as  nearly  aseptic  as  possible,  and  laboratories  for  inoculating  and 
sterilizing  are  among  the  necessary  features.  Although  tuberculosis 
is  seldom  encountered  in  calves,  yet  it  is  advisable  either  to  inject 
tuberculin  preceding  the  inoculation  or,  better,  after  collecting  the 
lymph,  that  the  calf  be  killed  and  a  careful  examination  made  by  one 
skilled  in  pathology  to  ascertain  if  the  animal  is  free  from  tuberculosis 
or  other  communicable  disease.  Calves  should  be  selected  that  have 
been  weaned,  preferably  from  four  to  six  months  old,  and  kept  in  a 

220  Chambou,  Menard,  and  Strauss:   Gaz.  des  H6p.,  December  15,  1892. 

221  Klein  (E.):  Report  of  medical  officer  to  the  Local  Government  Board  (London, 
1892). 

222  Leoni:   Revue  d'Hygiene,   August  20,   1894. 

223  Kinyoun:  Medical  News,  February  2,  1895. 


150  THE   ACUTE    EXANTHEMATA. 

separate  stable  for  some  weeks  to  eliminate,  so  far  as  possible,  any 
potent  source  of  infection,  such  as  aphthous  fever,  pleuro-pneumonia, 
etc.  After  this  stage  of  probation  the  animal  is  carefully  scrubbed 
with  potash  soap  and  water,  when  it  is  placed  in  the  inoculating  stable. 
This  should  be  constructed  in  accordance  with  the  most  approved 
plans,  with  cement  floors  and  walls  that  may  be  washed  frequently  with 
a  disinfecting  solution,  and  care  should  be  taken  that  the  most  scrupu- 
lous cleanliness  as  to  bedding  and  other  details  is  maintained.  In 
short,  the  same  care  is  here  required  that  is  necessary  in  a  hospital 
operating-room.  The  animal  is  placed  and  securely  fastened  on  a 
specially  constructed  table  and  the  abdomen  then  shaved  from  the  um- 
bilicus backward,  including  the  inner  surface  of  the  thighs.  This 
shaved  area  is  first  scrubbed  with  soap  and  warm  water  and  then  washed 
with  a  solution  of  corrosive  sublimate  (1  to  2000).  The  parts  are 
finally  rinsed  with  sterilized  water,  which  must  be  thoroughly  done, 
for  reasons  previously  given,  and  the  inoculations  are  thickly  made 
over  the  prepared  region.'  The  animal  is  then  released,  although  care 
must  be  taken  to  protect  the  vaccinated  area  from  being  licked  or 
molested  in  any  way.  About  the  seventh  day  the  calf  is  again  placed 
on  the  table  and  the  lymph  drawn.  Light  pressure  by  means  of  the 
blades  of  a  forceps  may  be  necessary  to  expel  the  lymph.  Copemann 
recommends  that  the  lymph  be  obtained  at  the  end  of  ninety-six  hours, 
by  means  of  a  steel  spoon  in  which  the  epithelium  and  underlying 
vesicular  pulp  are  removed,  avoiding,  as  far  as  possible,  the  admixture 
of  blood.  To  this  is  added  four  times  by  weight  of  a  sterilized  mixture 
of  50-per-cent.  chemically  pure  glycerin  and  water,  and  the  whole 
ground  to  a  fine  pulp,  which  may  be  preserved  in  the  usual  way.  To 
preserve  the  lymph  it  must  be  kept  away  from  the  light,  in  a  cool, 
even  temperature  ranging  from  40°  to  60°  F.  (4.4°  to  15.5°  C.). 

PEACTICE  OF  VACCINATION. 

Experience  has  shown  that  vaccination  may  be  performed  at  any 
age.  In  many  foundling  institutions  in  France  the  child  is  vaccinated 
when  a  few  days  old,  and,  according  to  Brouardel,  no  ill  effects  are 
noticed.  In  England  the  age-limit  for  compulsory  vaccination  is  three 
months  and  in  Scotland  six  months.  In  general,  with  the  presence  of 
small-pox  in  the  neighborhood,  or  when  traveling,  the  child  may  be 
vaccinated  at  any  age  should  occasion  require.  When  not  urgent,  it 
may  be  deferred  until  after  six  months.  It  is  usually  best  not  to  vac- 


VACCINIA.  151 

cinate  during  weaning,  teething,  change  of  diet,  excessive  heat,  etc., 
which  may  affect  the  general  health  of  the  child.  Likewise,  when 
debilitated,  or  during  the  progress  of,  or  convalescence  from,  any  dis- 
ease, it  may  be  postponed  unless  urgently  called  for.  Vaccination 
should,  if  possible,  be  avoided  when  erysipelas  is  in  the  home,  when 
scarlet  fever  or  measles  is  in  the  neighborhood,  or  when  the  child  is 
afflicted  with  any  acute  disease  of  the  skin,  such  as  eczema  or  impetigo. 
The  arm  is  usually  selected  at  the  insertion  of  the  deltoid  muscle, 
although,  in  girls,  the  leg  may  be  preferred  on  account  of  the  dis- 
figuring scar  which  is  liable  to  follow.  The  parts  should  then  be  bared, 
care  being  taken  that  the  clothing  does  not  constrict  free  circulation, 
and  scrubbed  with  potash  soap  and  hot  water  and  dried  with  a  steril- 
ized towel.  When  the  surroundings  call  for  additional  precautions,  the 
washing  may  be  followed  by  alcohol  or  ether.  After  the  use  of  alcohol 
or  ether  as  a  detergent  the  arm  must  be  thoroughly  flushed  with  ster- 
ilized water  (water  having  previously  been  boiled),  to  obviate  the  dan- 
ger of  sterilizing  the  lymph.  When  dry,  the  epidermis  should  be  torn 
up  by  means  of  a  needle,  previously  passed  through  the  flame  of  a 
spirit-lamp  or  Bunsen  burner,  until  a  serous  exudate  occurs,  or  at  most 
but  a  faint  trace  of  blood.  It  is  advisable  to  expose  an  area  of  about 
half  an  inch  in  diameter  (1.2  centimetres)  to  the  action  of  the  virus, 
which  may  be  divided  into  two  or  more  denuded  areas.  When  multi- 
ple, they  should  be  fully  one  and  a  half  inches  (4  centimetres)  apart, 
to  obviate  the  merging  of  their  margins  in  case  of  pus-infection  or 
when  otherwise  irritated.  The  content  of  one  tube  is  then  scratched 
into  the  denuded  surface  and  allowed  to  dry,  after  which  it  should  be 
covered  with  sterilized  cotton-wool,  to  protect  against  contamination, 
and  held  in  place  by  adhesive  straps  or  better  painted  with  flexible 
collodion.  In  general,  the  larger  the  vaccinal  scar,  the  greater  the 
protection  from  small-pox.  This  was  clearly  shown  in  the  findings  of 
the  Royal  Commission,  and  is  the  common  observation  of  clinicians, 
although  the  writer  agrees  with  Welch  (W.  M.,  loc.  cit.)  that  the  quality, 
as  well  as  the  quantity,  of  lymph  absorbed  should  be  taken  into  account. 
It  is  advisable  that  the  medical  man  should  inspect  the  arm  on  or  about 
the  fifth,  and  again  on  the  seventh  or  eighth  day,  and  at  least  once 
thereafter,  iisually  about  the  eighteenth  day.  In  primary  vaccination, 
when  urgent,  the  operation  should  be  repeated  if  at  the  end  of  from 
a  week  to  a  fortnight  no  symptoms  of  a  successful  vaccinal  pock  appear. 
When  no  special  danger  of  infection  exists,  it  is  advisable,  especially  in 
very  young  infants,  to  defer  revaccination  for  a  month,  or  until  the 
effects  of  the  first  have  wholly  passed  away. 


CHAPTER  IV. 
VARICELLA.224 

(Chicken-pox,225  formerly,  water-pock,  glass-pock,  swine-pox, 
etc.;  German,  taricellen,  icasserpocken,  windblattern,  schafpocken; 
French,  varicelle,  la  rerolette;  Italian,  morviglione,  ravaqlione; 
Latin,  variola  notha  sen  spvria.) 

DEFINITION. 

VARICELLA  is  an  acute,  specific,  mildly  infectious  eruptive  dis- 
order, met  with  in  childhood,  characterized  by  a  cutaneous  exanthem 
of  vesicular  type,  which  comes  out  in  successive  crops,  and  is  accom- 
panied by  mild  febrile  symptoms.  The  eruption  terminates  by  desic- 
cation and  the  formation  of  superficial  crusts  in  from  three  to  five 
days.  One  attack  confers  immunity  for  the  rest  of  life.  Although 
resembling  variola  in  some  particulars,  it  has  no  relation  to  that  dis- 
ease. 

That  the  Arabians  were  familiar  with  varicella  seems  highly  prob- 
able (see  page  11).  Be  this  as  it  may,  it  is  unquestionably  true  that 
the  disease  was  again  lost  sight  of  for  many  centuries  (see  page  18), 
and  seems  not  to  have  been  accurately  described  by  Sydenham,  al- 
though Riviere226  gave  a  clear  description  of  the  disease  as  it  appeared 
in  France  in  1641.  A  few  years  later,  however,  Morton  (1690)  de- 
scribed several  cases  under  the  title  variola  maxime  benigna,  which 
was  probably  the  first  clinical  description  of  the  disease  in  Eng- 
land. Harvey,  in  1696,  likewise  contributed  to  the  literature  of  this 
subject  (Thomas).  According  to  Gregory,227  the  term  "chicken-pox" 
was  introduced  by  Morton  at  this  time.228  Half  a  century  later 
Fuller229  (1730)  attempted  in  unmistakable  terms  to  separate  it  from 
variola,  with  which  it  was  apparently  inextricably  confounded.  The 
quaint,  though  forcible,  logic  employed  by  this  writer  in  asserting  the 
doctrine  of  the  duality  of  variola  and  varicella  has  never  been  sur- 


224  Formerly  sometimes  written  varicella,  diminutive  of  ranis,  a  pimple  or  pock. 
226  Probably  derived  from  the  Latin,  deer,  or  the  French,  chiche,  insignificant. 
*»  Rivifcre:  "Prax.  med."  (Lugd.,  1660). 

22r Gregory  (George):  "Theory  and  Practice  of  Physic"  (Philadelphia  edition,  1829), 
vol.  i. 

228  Morton  (R.):   "Opera  Medica"  (Amstelodami,  1696),  tome  Hi,  p.  58. 

229  Fuller,   quoted  by  Gee  (S.   J.),  under   "Varicella,"   in  Reynolds's  "System  of 
Medicine"  (London,  1870),  vol.  i,  p.  217. 

(152) 


VARICELLA.  153 

passed  in  more  classic  words:  "The  pestilence  can  never  breed  the 
small-pox,  nor  the  small-pox  the  measles,  nor  the  crystals  or  chicken- 
pox,  any  more  than  a  hen  can  breed  a  duck,  a  wolf  a  sheep,  or  a 
thistle  figs;  and  consequently  one  sort  cannot  be  preservative  against 
any  other  sort." 

Varicella  seems  to  have  first  been  described  in  Germany  by  Sen- 
nert230  in  1676,  although  this  description  is  somewhat  ambiguous,  while 
the  term  varicella  was  first  applied  to  this  disease  by  Yogel231  in  1764. 
At  this  time  the  disease  attracted  wide  attention  because  of  its  mild 
nature,  contrasting  strongly  with  its  formidable  rival  variola,  which 
raged  with  appalling  consequences.  The  next  writer  of  note  was 
Heberden,232  who  forcibly  contended  for  the  duality  of  variola  or  vario- 
loid  and  varicella.  For  fully  fifty  years  his  work  was  looked  upon  as 
the  leading  authority,  and  unquestionably  did  more  to  enable  phy- 
sicians to  differentiate  between  small-pox  and  varicella  than  any  pre- 
vious or  subsequent  writer  of  the  eighteenth  century.  Next  came 
Frank,233  of  Vienna,  who,  in  1805,  made  important  contributions  to 
the  literature  of  the  disease.  He  was  followed  by  Heim,234  of  Berlin, 
although  much  confusion  crept  into  literature  by  the  various  synonyms 
and  errors  made  by  different  observers  in  distinguishing  between  mild 
cases  of  variola  and  varicella.  Heim  called  attention  to  the  non-in- 
oculability  of  varicella,  and  mentioned  other  distinguishing  features. 
He  likewise  dwelt  upon  the  superficial  character  of  the  lesions,  and 
the  strong  contrast  shown  to  the  deep-seated  pocks  of  variola,  which 
to-day  we  emphasize  as  one  of  the  most  valuable  points  in  differ- 
entiating between  them.  Xo  writer,  however,  entered  into  the  minute 
appearances  of  the  two  eruptions,  nor  gave  a  clearer  description  of  the 
disease  itself  than  did  Wilan  in  1806.  He  spoke  of  the  peculiar  "len- 
ticular," "conoidal,"  and  "globate"  forms  of  the  lesions. 

With  the  general  introduction  of  the  practice  of  vaccination  at 
the  beginning  of  the  nineteenth  century  many  more  cases  of  variola 
became  so  modified  as  to  present  even  a  closer  clinical  appearance  to 
varicella,  which  added  to  the  confusion  already  experienced.  This,  it 
may  be  remarked,  continues  in  some  not  very  remote  parts  of  the  globe 

^Sennert:  "Opr.  Omn.  in-fol"  (Lugduni,  1676).  Vide  Rayer  (Paris,  1835),  vol.  i, 
p.  564. 

281  Vogel  (R.  A.),  1772.  Vide  Bohn,  in  Gerhardt's  "Handbuch  der  Kinderkrank- 
heiten"  (Tubingen,  1877),  p.  325. 

232  Heberden:  "Transactions  of  the  Royal  College  of  Physicians";  also  "Commen- 
taries on  the  History  and  Cure  of  Diseases"  (Boston  edition,  1818),  vol.  i,  p.  427,  1767. 

283  Frank:    "Traitg  de  med.  pratiq.,"  trad,  par  Goudareau,  8  (Paris,  1820),  tome  ii. 

^  Heim:  In  Horn's  Archiv  fur  praktiscbe  Medicin  und  Klinik.,  B.  7,  H.  2,  S.  183. 


154  THE   ACUTE    EXANTHEMATA. 

to  the  present  day.  It  is  not  strange,  therefore,  that  a  wide  difference 
of  opinion  existed  as  to  the  identity  and  non-identity  of  the  two  affec- 
tions. During  the  years  1818-19  an  epidemic  of  what  was  supposed 
to  be  chicken-pox  prevailed  in  Scotland,  which  was  reported  by  Thom- 
son,235 of  Edinburgh,  who  further  retarded  the  process  of  differentia- 
tion by  affirming  that  varicella  was  only  a  mild  manifestation  of  the 
variolous  poison.  He  was  followed  by  Hebra,  of  Vienna,  who,  for 
nearly  a  half  century  expounded  the  belief  that  varicella  was  but  a 
modified  form  of  variola.  Probably  no  author  of  wide  clinical  ex- 
perience at  the  present  day  doubts  the  non-identity  of  the  two  diseases, 
and,  like  the  final  differentiation  and  establishment  of  rubella,  vari- 
cella has  gradually  emerged  from  the  state  of  confusion  in  which  it  has 
for  centuries  existed,  and  through  the  slow  process  of  evolution  in 
medicine  is  now  almost  universally  regarded  as  a  specific  and  distinct 
disease. 

SYMPTOMATOLOGY. 

LATENT  STAGE,  OR  PERIOD  OF  INCUBATION. — This  varies  from 
ten  to  nineteen  days,  although  it  is  usually  conceded  to  be  most  fre- 
quently fourteen  days  from  the  time  of  exposure  to  the  appearance  of 
the  rash.  Thomas  found  it  approximately  from  thirteen  to  seventeen 
days,  and  somewhat  longer  than  in  both  variola  and  morbilli.  This 
agrees  with  the  period  given  by  Gee,236  Trousseau  (loc.  cit.,  p.  136),  and 
Hesse,237  although  shorter  periods  have  been  reported  by  Sykes238  and 
others.  Steiner239  found  the  period  of  incubation  after  inoculation 
to  be  uniformly  eight  days  in  eight  cases,  while  MacCombie240  gives 
ten  days  as  the  usual  period  after  inoculation.  The  period  of  incuba- 
tion, therefore,  is  about  the  same  as  observed  in  variola.  During  this 
time  no  symptoms  are  apparent. 

PRODROMAL  STAGE. — In  may  cases  during  this  time  no  evidence 
of  infection  is  present;  at  least  no  symptoms  are  observed  before  the 
appearance  of  the  eruption.  In  50  per  cent.,  or  4  of  Steiner's  cases, 
mild  febrile  symptoms  were  observed,  and  in  4  no  disturbance  what- 
ever occurred  before  the  eruption  appeared.  Properly  speaking,  there- 
fore, there  is,  in  a  large  number  of  cases,  no  prodromal  stage.  At 
times,  however,  it  is  noticed  that  the  child  is  restless  and  fretful,  again 


255  Thomson  (John):  Edinburgh  Med.  and  Surg.  Jour.,  1818,  vol.  xiv,  pp.  518-657. 
284  Gee:  "Varicella,"  in  Reynolds's  "System  of  Medicine"  (London,  1870),  vol.  i. 
887  Hesse:  "Ueber  Varicellen,"  etc.  (Leipzig,  1829). 

238  Sykes:  Brit.  Med.  Jour.,  1899,  i,  p.  81. 

239  Steiner:  Wiener  med.  Woch.,  No.  16,  1875. 

240  MacCombie:  Allbutt's  "System,"  article  "Chicken-pox"  (op.  cit.). 


VARICELLA.  155 

dull  and  apathetic,  a  few  hours — or  it  may  be  a  day  or  two — before 
the  eruption  appears.  Of  43  cases  in  which  careful  notes  were  taken 
by  the  writer,  19  showed  no  premonitory  symptoms,  nor  could  any  rise 
of  temperature  be  detected;  in  24  there  were  mild  febrile  symptoms 
present  to  a  greater  or  less  degree,  among  which  were  slight  anorexia 
in  20,  irritability  in  17,  lassitude  in  10,  headache  in  4,  slight  pain 
in  the  back  and  limbs  in  2,  chilliness  in  9,  nausea  in  4,  and  vomiting 
in  2.  These  premonitory  symptoms  were  of  short  duration,  and  varied 
from  two  to  thirty-six  hours  immediately  preceding  the  eruption.  In 
most  of  these  cases  there  was  a  slight  rise  of  temperature  the  evening 
preceding  the  first  crop  of  lesions,  which  were  visible  on  the  following 
morning  or  during  the  day.  In  27  cases  Hyde241  failed  to  observe  any 
premonitory  symptoms.  From  further  observation  in  asylums  and 
similar  institutions  I  believe  that  it  is  not  uncommon  to  detect  a 
slight  rise  of  temperature  a  few  hours  preceding  the  rash.  This  is 
never  high,  ranging  from  99°  to  102°  F.  (37.2°  to  38.8°  C.),  nor  of  long 
duration,  and  sometimes  ends  with  the  outbreak  of  the  exanthem.  A 
higher  temperature  should  be  looked  upon  with  suspicion,  lest  it  fore- 
bode a  more  serious  affection. 

In  private  practice  the  most  watchful  mothers  usually  detect  no 
derangement  in  the  usual  health  of  the  child  before  the  rash  appears, 
and  in  but  few  instances  has  the  writer  ever  observed  serious  disturb- 
ances which  could  be  attributed  to  the  poison  of  varicella.  All  writers 
on  varicella  ascribe  considerable  diagnostic  importance  to  the  absence 
of  fever  and  prodromal  symptoms.  According  to  Heberden,  they  are 
absent  or  slight;  no  symptoms  are  noticed  before  the  eruption,  says 
Gregory.  The  same  opinion  prevails  among  more  recent  authors,  while 
many  cite  numerous  exceptions  to  the  rule.  Liveing  says  the  premoni- 
tory symptoms  are  often  very  slight,  indeed,  or  not  observed  at  all, 
while  sometimes  they  are  well  marked.  Holt  says  that  rarely  for  more 
than  half  a  day  and  in  many  cases  no  prodromata  whatever  are  noticed, 
the  rash  being  the  first  thing  to  attract  attention.  This  view  is  like- 
wise held  by  MacCombie.  Henoch242  believes  it  is  the  rule  for  the 
exanthem  to  appear  without  any  prodromal  symptoms,  and  only  a  few 
times  before  the  eruption  appeared  has  he  observed  headache,  vomiting, 
or  fever,  and  still  more  rarely  a  slight  conjunctivitis  or  angina.  In  one 
instance  a  copious  prodromal  rash  occurred,  with  high  fever  and  con- 


211  Hyde  (J.   Nevins) :    "Varicella,"  In  Pepper's  "System  of  Med."   (Philadelphia, 
1885). 

242  Henoch:  "Vorlesungen  tiber  Kinderkrankheiten"   (Wien,  1890),  p.  211. 


156  THE    ACUTE    EXANTHEMATA. 

vulsions,  which  disappeared  in  twenty-four  hours.  Thomas  took  the 
temperature  twice  daily  just  preceding  the  attack  without  detecting, 
excepting  in  a  few  instances,  any  appreciable  rise  of  temperature.  He 
concludes,  therefore,  that  a  precursory  stage  manifested  by  an  increase 
of  temperature  does  not,  in  most  cases,  exist,  and  in  the  few  rare  cases 
in  which  it  is  found  it  is  quite  insignificant  and  only  of  a  few  hours' 
duration.  Sometimes,  he  continues,  the  rise  of  temperature  is  coin- 
cident with  the  beginning  of  the  eruption. 

In  more  recent  observations  the  same  author243  found  in  five  cases, 
taken  per  rectum  every  two  hours,  a  slight  rise  of  temperature,  100.9° 
F.  (38.2°  C.),  preceding  the  eruption.  In  a  second  series  the  following 
was  recorded: — 

In     2  cases  the  highest  temperature  was  100.9°  F.  (38.5°  C.). 

"11       "  "  "      102.2°  F.  (39.0°  C.). 

"    15       "        "  "      103.1°  F.  (39.5°  C.). 

"    10       "        "  "      104.0°  F.  (40.0°  C.). 

"      6       "        "  "      104.9°  F.  (40.5°  C.). 

"      1  case      "  "      105.8°  F.  (41.0°  C.). 

According  to  Gerhardt,244  the  disease  begins  with  a  slight  chill, 
which  is  sometimes  followed  by  a  rapid  rise  of  temperature.  This  is 
accompanied  at  times  by  pain  in  the  back  and  extremities,  which  some- 
times continues  three  days  or  longer,  although  most  frequently  from 
one-half  to  one  day.  Bohn245  gives  the  following  sequence  of  symp- 
toms as  the  most  usual:  In  a  previously  healthy  child  there  is  often 
slight  pallor  observed  for  about  half  a  day.  At  the  same  time  it  may 
be  seen  that  he  is  listless,  easily  fatigued,  and  has  lost  his  usual  appe- 
tite. During  the  following  night  he  sleeps  restlessly,  is  feverish,  and 
the  next  morning  it  is  observed  that  he  has  an  eruption. 

Von  Jiirgensen246  believes  that,  as  is  usual  in  the  other  infectious 
diseases,  a  slight  rise  of  temperature  in  varicella  is  to  be  expected, 
and  that  the  amount  of  fever  will  naturally  correspond  to  the  severity 
of  the  disease.  As  illustrating  the  wide  divergence  of  symptoms 
which  the  varicella  poison  may  produce  in  different  individuals,  he 
cites  Tham's247  report  of  a  child,  three  and  a  half  years  old,  having 
severe  nervous  symptoms,  with  difficulty  of  breathing,  convulsions, 
slow  pulse,  shivering,  and  a  subnormal  temperature.  Fourteen  days 

243  Thomas:  Archiv  f.  Derm.  u.  Syph.,  B.  1,  S.  335. 

^Gerhardt  (C.):  "Lehrbuch  der  Kinderheilkunden"   (Tubingen,  1877). 
^Bobn:  "Varicella,"  in  Gerhardt's  "Handbuch,"  etc.  (loc.  cit.),  S.  328. 
248  Von  Jiirgensen  (Theodor):  "Acute  Exantbeme,  Scharlach,  Rotheln,  Varicellen," 
in  Nothnagel's  "Specielle  Patb.  und  Therap."  (Wien,  1896),  B.  4,  p.  294. 

"'Tham:  "Jahrbuch  fur  Kinderheilkunde,  Neue  Folge,"  B.  25,  S.  155-56. 


VARICELLA.  157 

later  a  sister  of  the  patient  came  down  with  a  mild  form  of  vari- 
cella, which  ran  its  usual  course.  Thus,  there  seems  to  be  a  uniformity 
of  opinion  as  to  the  uncertain  value  or  total  absence  of  anything  to 
indicate  the  presence  of  varicella  in  the  system  until  the  advent  of  the 
exanthem.  This  offers  a  striking  contrast  to  that  presented  in  even 
the  mildest  cases  of  variola.  At  the  same  time  it  must  be  conceded 
that  in  varicella,  as  in  other  diseases,  there  are  many  exceptions,  some 
of  which  may  be  directly  due  to  the  effect  of  the  varicella  poison  on 
very  impressionable  children;  others  must  be  ascribed  to  extraneous 
diseases  having  no  relationship  with  varicella  excepting  their  coin- 
cidence in  the  same  individual.  In  addition  to  the  febrile  symptoms 
previously  given,  those  of  a  more  severe  character  are  occasionally  en- 
countered, such  as  delirium  (MacCombie)  and  convulsions  (Henoch, 
Jennings).  According  to  the  author  first  named,  in  haemorrhagic  cases 
the  rise  of  temperature  may  precede  the  eruption  two  or  three  days, 
during  which  time  there  may  be  repeated  hasmatemesis,  bloody  stools, 
followed  by  subnormal  temperature  and  collapse.  A  supposed  case  of 
this  kind  which  terminated  fatally  occurred  in  Cleveland  during  the 
past  winter,  in  which  all  of  the  inmates  of  the  house,  not  vaccinated, 
in  due  time  came  down  with  variola.  It  would  be  safer,  therefore, 
with  Henoch  (loc.  cit.,  p.  711),  to  look  upon  all  severe  symptoms  dur- 
ing the  invasion  stage  as  accidental,  and  not  essentially  associated  with 
varicella. 

THE  ERUPTIVE  STAGE,  OR  PERIOD  or  ERUPTION. — This,  prac- 
tically, in  the  majority  of  cases,  marks  the  onset  of  the  disease.  The 
mother  or  nurse  usually  first  discovers  an  eruption  when  dressing  or 
bathing  the  child.  It  is  usually  first  seen  on  the  upper  part  of  the  back, 
where  it  attains  its  most  characteristic  development.  Next  it  appears 
on  other  parts  of  the  trunk,  scalp,  face,  upper  and  lower  extremities, 
although  usually  to  a  less  extent.  Very  often  several  regions  are  at- 
tacked simultaneously,  as  the  upper  part  of  the  trunk  and  scalp,  it 
never  following  the  order  of  development  observed  in  variola.  It  may 
appear  also  on  the  palms  of  the  hands  and  soles  of  the  feet,  although 
but  one  or  two,  sometimes  more,  lesions  are  usually  found.  In  several 
instances  photographs  of  this  palmar  and  plantar  eruption  have  been 
procured  by  the  writer. 

The  individual  lesions  first  appear  as  erythematous  spots,  which 
disappear  on  pressure  or  by  stretching  the  skin,  and,  as  Trousseau  (loc. 
cit.,  p.  134)  very  aptly  says,  are  similar  to  those  observed  on  the  abdo- 
men in  enteric  fever.  They  are  rose  red  in  color,  and  spread  out  at  the 


158  THE   ACUTE    EXANTHEMATA. 

periphery,  usually  following  the  grain  or  cleavage  lines  of  the  skin, 
thus  often  becoming  oblong  or  oval  in  shape,  although,  as  the  erythem- 
atous  macules  gradually  blend  with  the  surrounding  integument,  this 
may  not  at  first  sight  be  apparent  (Plate  XXV).  At  this  time  they 
are  larger  than  observed  in  variola,  and  resemble  somewhat  those  pro- 
duced by  the  sting  of  insects.  They  range  from  one-quarter  to  one- 
half  inch  (0.5  to  1.2  centimetres)  in  diameter,  and  in  number  vary  from 
about  half  a  dozen  to  twenty  or  more.  According  to  Trousseau  (loc. 
tit.,  p.  134),  the  eruption  appears  in  the  form  of  small  rosy  spots, 
slightly  acuminated,  and  in  number  vary  from  ten  to  fifteen  the  first 
day,  appearing  on  any  part  of  the  body,  while  Bryce248  and  Gregory 
(loc.  cit.)  describe  an  eruption  of  vesicles  as  the  first  thing  seen. 

Von  Jiirgensen  observed  the  eruption  first  on  the  scalp,  then  on 
the  face,  neck,  and  upper  part  of  the  trunk,  following  the  same  order 
of  invasion  common  in  the  other  diseases  of  this  class.  According  to 
Whittaker,249  it  first  appears  on  the  neck  and  chest;  Liveing  first 
noticed  it  on  the  back  and  chest;  and  MacCombie  says  it  first  appears 
almost  invariably  on  the  back,  chest,  and  abdomen,  but  occasionally 
first  on  the  face  or  the  extremities,  with  which  the  writer's  experience 
wholly  agrees.  Local  irritation  may  not  only  determine  the  first  ap- 
pearance of  the  eruption,  but  renders  it  more  copious,  as  is  often  seen 
on  parts  irritated  by  the  clothing,  or  from  bands,  garters,  and  more 
especially  on  the  buttocks  from  diapers.  In  this  respect  it  resembles 
variola,  while  it  differs  in  that  the  exposed  surfaces  are  usually  the  least 
involved. 

The  evolution  of  the  spot  is  rapid.  Within  from  one  to  three  hours 
after  its  appearance  a  pin-head-sized  acumination  or  slight  thickening 
may  be  perceptible  above  the  general  niveau  of  the  skin,  which  soon  be- 
comes transparent,  and  a  vesicle  is  formed.  This  increases  in  size  until 
the  dimensions  of  a  lentil  or  a  split  pea  are  attained.  They  usually  stand 
out  in  bold  relief  (Plate  XXVI);  are  tense,  with  a  broad  areola;  and  are 
easily  ruptured.  After  rupturing  or  being  pricked  with  a  pin,  a  serous, 
translucent  fluid  escapes  and  the  wall  collapses  to  the  general  level  of 
the  surrounding  integument,  or  the  lesion  may  not  completely  empty 
itself,  and  remains  slightly  elevated.  Much  stress  is  laid  on  the  evacua- 
tion of  the  varicella  lesion  for  diagnostic  purposes.  While  the  vesicle 
is  not  always  unicellular,  there  are  fewer  trabeculaa  than  in  the  variola 


248  Bryce:  Edinburgh  Med.  and  Surg.  Jour.,  vol.  xiv,  p.  467. 

249  Whittaker   (James  T.):   "Varicella,"   in  Pepper's  "Amer.   Text-book  of  Theory 
and  Pract.  of  Med."  (Philadelphia,  1893),  vol.  i,  p.  299. 


PLATE  XXV. 


PLATE  XXV. 


Varicella,    showing  Typical    Distribution,    with   Areola  well    Marked. 


PLATE  XXVI. 


PLATE  XXVI. 


Varicella,    showing   Contour  of  the    Lesions,    with   Areola. 


VARICELLA.  159 

pustule,  as  may  be  readily  verified  by  means  of  a  needle.  This  has 
been  demonstrated  many  times  before  medical  classes  in  differentiating 
between  varicella  and  variola.  The  individual  lesion  matures  in  from 
six  to  twenty-four  hours,  when  involution  begins.  Not  all  the  ery- 
thematous  blotches  develop  into  vesicles;  many  fade  away  before  the 
following  day,  leaving  no  trace  behind.  Others  give  rise  to  vesicles 
without  the  intermediate  formation  of  a  papule  or  any  perceptible 
elevation  in  the  integument.  More  rarely  vesicles  spring  up  from  ap- 
parently normal  skin.  All  of  these  forms  may  sometimes  be  seen  at 
one  time.  Bohn  (loc.  cit.,  p.  329)  says  the  vesicle  never  develops  from 
a  papular  base;  Thomas  (loc.  cit.,  p.  11)  holds  that  the  characteristic 
varicella  vesicle  first  appears  in  the  centre  of  the  initial  hyperaemia.  In 
this  respect  it  differs  widely  from  that  observed  in  variola.  On  the 
palms  and  soles  the  vesicular  covering  is  thicker,  and  the  lesion  appears 
more  deep-seated,  and  usually  disappears  by  resorption  rather  than 
from  rupture  of  the  vesicle  wall. 

The  first  outbreak  may  complete  the  eruptive  stage;  more  com- 
monly on  the  following  day,  or  within  a  few  hours,  new  lesions  appear, 
in  character  similar  to  those  previously  observed,  excepting  that  in  the 
second  and  third  crops  they  are  often  more  plentiful  and  of  a  larger 
size.  Several  crops  or  groups  of  new  lesions  may  appear  for  several 
days,  until  in  number  they  vary  from  a  half-dozen  to  two  hundred  or 
more.  They  are  always  discrete,  although  when  two  lesions  occur  close 
together  they  may  blend,  forming  a  single,  elongated,  bean-shaped 
vesicle.  In  the  meantime  the  lesions  first  formed  take  on  an  opaque 
or  slightly  yellowish  color,  although  the  contents  never,  unless  the  wall 
has  been  ruptured,  become  thick  and  creamy  as  in  variola.  Many  of 
the  lesions,  however,  do  become  denuded  from  scratching  or  rubbing 
of  the  clothing,  when  true  pustules,  covered  by  a  brownish  crust,  may 
be  seen.  Eesorption  takes  place,  in  others,  leaving  a  slightly  elevated 
papule  surmounted  by  an  easily  detached  crust.  Commonly  new  lesions 
appear  without  order  either  as  to  time  or  distribution,  although  the 
extremities  are  usually  last  affected.  In  this  the  eruption  is  essentially 
polymorphous;  that  is,  macules  or  erythematous  spots  intermingle 
with  vesicles  in  different  stages  of  development,  together  with  light- 
colored  pustules,  crusts,  and  small  excoriated  areas  or  papules.  It  is 
well  to  Bear  in  mind  that  essentially  the  typical  varicella  lesion  is  non- 
indurated  and  when  ruptured  collapses,  especially  in  the  centre,  and 
tends  to  conform  to  the  general  level  of  the  skin.  Inflammatory  dis- 
turbances induced  by  the  introduction  of  pus  organisms  and  other 


160  THE   ACUTE    EXANTHEMATA. 

pathogenic  substances  frequently  complicate  the  simple  process  ob- 
served in  varicella  and  render  the  disease  more  or  less  protracted. 

The  mucous  membranes  are  likewise  affected  in  varicella,  but 
never,  so  far  as  I  am  aware,  until  the  exanthem  appears.  In  fact,  in 
cases  observed  with  special  reference  to  this  point,  the  enanthem 
seemed  to  be  coincident  with  the  exanthem.  At  other  times  it  ap- 
peared only  at  the  height  of  the  cutaneous  eruption,  and  in  some  in- 
stances no  disturbance  whatsoever  could  be  detected.  When  present, 
the  lesions  are  most  commonly  seen  on  the  soft  palate,  less  frequently 
on  the  hard  palate,  inner  surface  of  the  cheeks  and  tongue,  and  on 
other  parts  of  the  mouth  and  throat.  Not  infrequently  they  appear  on 
the  vaginal  mucous  membrane,  and  sometimes  on  the  prepuce  of  boys. 
Both  Thomas  and  Henoch  have  reported  vesicles  on  the  conjunctiva, 
In  these  positions  the  lesions  conform  somewhat  in  character  to  those 
observed  on  the  skin,  namely:  the  formation  of  transparent,  thin- 
walled  vesicles,  surrounded  by  an  erythematous  halo.  In  the  mouth 
the  epithelial  covering  soon  becomes  denuded,  leaving  reddish,  ex- 
coriated spots,  which  may  readily  be  mistaken  for  aphthous  stomatitis. 
They  are  usually  few  in  number  and  quickly  disappear. 

The  subjective  symptoms  during  the  eruptive  period  are  always 
slight,  and  may  be  entirely  absent.  When  prodromal  symptoms  are 
present  they  may  also  disappear  with  the  appearance  of  the  rash.  With 
each  crop  of  vesicles  there  is  usually  a  slight  rise  of  temperature. 
Sometimes  this  subsides  between  the  cutaneous  outbreaks,  sometimes 
it  is  continuous,  with  morning  remissions,  during  the  whole  eruptive 
period.  The  temperature  scarcely  ever  rises  more  than  2  or  3  degrees. 
The  slight  febrile  disturbance  does  not,  however,  interfere  perceptibly 
with  the  cheerfulness  of  the  child  nor  his  relish  for  food,  and  in  many 
cases  children  play  about  much  as  they  are  accustomed  to  do  in  health. 
Such  cases  frequently  present  themselves  at  public  clinics,  and  I  know 
of  no  instance  in  which  harm  has  resulted  from  this  exposure  even 
during  the  winter  months.  Sometimes,  toward  evening,  the  child  be- 
comes peevish,  and  during  the  night  sleep  may  be  more  or  less  restless; 
otherwise  no  general  symptoms  are,  as  a  rule,  present. 

In  other  cases,  and  in  the  majority  of  strumous  and  asylum  chil- 
dren, according  to  my  observation,  the  eruption  is  accompanied  by 
definite  symptoms,  more  especially  referable  to  the  influence  of  the 
varicella  poison  on  the  nerve-centres,  in  which  case  the  child  is  dull 
or  sleepy  during  the  day,  is  sometimes  chilly,  has  marked  loss  of  ap- 
petite with  thirst,  is  sometimes  constipated,  and  is  excitable  or  wakeful 


PLATE  XXVII. 


PLATE  XXVIII. 


XXVIII 
VARICELLA — showing  posterior  view  of  one  in  the  preceding. 


PLATE  XXIX. 


PLATE  XXTX. 


Varicella   resembling   Vanoloid. 


VARICELLA.  161 

at  night.  More  rarely,  according  to  Jennings,250  the  throat  is  slightly 
sore  and  the  lymphatic  glands  are  swollen  and  tender.  This  the  present 
writer  has  never  seen. 

From  the  foregoing  it  will  appear  that  the  stage  of  desquamation 
begins  a  few  hours  after  the  appearance  of  the  eruptions,  and  goes  on 
pari  passu  with  the  development  of  the  lesions.  As  soon  as  resolution 
begins,  itching  may  be  troublesome,  and  in  this  way  the  vesicles  become 
denuded  from  scratching. 


COMPLICATIONS  AND  SEQUELS. 

Varicella  is  remarkably  free  from  complications,  and  ill  effects 
from  the  disease  in  an  otherwise  healthy  child  may  never  occur  in  the 
practice  of  many  physicians  of  wide  experience.  In  very  delicate 
subjects,  however,  a  period  of  ill  health  is  sometimes  observed  to 
follow  varicella,  as  from  any  other  slight  constitutional  disturbance. 
The  most  frequent  concomitants,  so  far  as  the  writer  has  observed, 
arise  from  the  numerous  foci  exposed  to  local  infection.  It  is  a 
matter  of  surprise  that  more  cases  of  secondary  infection  do  not  occur, 
when  we  consider  the  number  of  denuded  areas  through  which  bac- 
teria and  cocci  ma}'  readily  gain  entrance.  From  this  cause  severe 
inflammation  of  the  vesicles  sometimes  occurs,  or  they  extend  at  the 
periphery  much  as  is  seen  in  impetigo  and  similar  affections,  and  prob- 
ably from  the  same  cause,  namely:  the  development  of  various  micro- 
organisms. The  cases  of  impetigo  reported  by  Descroizilles,251  the 
stafilococcia  varicellosa  of  Bolognini,252  the  varicella-prurigo  of  Hutch- 
inson,253  and  those  of  bullous  varicella  by  Pye-Smith254  may  be  cited 
as  belonging  to  this  class.  In  more  destructive  processes  deep  ulcers 
or  gangrene  may  ensue.  Such  a  case  came  under  the  writer's  observa- 
tion during  the  past  year  in  consultation  with  a  colleague,  in  which 
some  of  the  lesions,  instead  of  healing,  became  angry,  dark  colored, 
and  finally  necrotic.  Only  eight  or  ten  lesions  were  thus  affected, 
some  of  them  but  slightly.  They  were  all  situated  on  the  lower  part 
of  the  trunk  and  thighs.  In  the  course  of  three  or  four  weeks  healthy 
granulations  appeared,  and  finally  the  patient  recovered,  with  depressed 


250  Jennings:   "Varicella,"  in  Heating's  "Cyclopaedia  of  the  Diseases  of  Children" 
(Philadelphia,  1889),  vol.  i,  p.  762. 

251  Descroizilles  (A.):  France  med.  (Paris,  1898),  xlv,  657. 
262  Bolognini  (P.):  Pediatria  (Napoli,  1897),  vol.  76-80. 

253  Hutchinson  (Jonathan):  "Clinical  Lectures"  (London,  1879),  vol.  i,  pp.  15  ft  seq. 

254  Pye-Smith:  Brit.  Jour,  of  Derm.,  1897,  vol.  ix,  p.  148. 


162  THE   ACUTE    EXANTHEMATA. 

cicatrices  marking  the  gangrenous  areas.  Cultures  made  from  the  ne- 
crosed material  showed  a  mixed  infection,  in  which  the  streptococcus 
pyogenes  was  found.  The  cases  of  varicella  gangrenosa  reported  by 
Tlutchinson,255  Howard,256  Crocker,257  Vierordt,258  Loekwood,259  and 
Silver260  seem  to  belong  to  the  same  category.  The  writer  would  there- 
fore place  the  formation  of  bullae,  undue  inflammation,  ulceration,  and 
gangrene  as  instances  of  mixed  secondary  infection  rather  than  as  spe- 
cial varieties  of  varicella. 

Varicella  Hcemorrliagica. — Haemorrhagic  varicella  has  been  occa- 
sionally seen.  Ploc2G1  and  Andrew262  have  observed  it  as  a  complica- 
tion in  cachectic  cases.  According  to  MacCombie,  large  and  small 
ecchymoses  appear,  with  hemorrhage  into  the  cutis  under  the  vesicle, 
accompanied  by  haematemesis  and  melaena;  and,  while  the  symptoms 
are  severe,  recovery  usually  takes  place.  It  is  an  extremely  infrequent 
complication,  and  occurs  in  certain  cachectic  or  debilitated  subjects, 
and  more  especially  in  the  so-called  "bleeders" — persons  having  haemol- 
ysis or  haemophilia. 

Acute  nephritis  sometimes  arises  during  the  course  of  varicella, 
and,  as  in  scarlatina,  may  be  a  serious  complication.  Such  cases  have 
been  reported  by  Henoch,263  Eille,264  Janssen,265  Openheim,266  von 
Jiirgensen  (op.  cit.,  p.  300),  Hb'gyes,267  Silver  (loc.  cit.},  Easch,268 
linger,  and  others.  In  most  of  these  cases  the  nephritis  appeared  after 
the  decline  of  the  eruption,  and  in  one  instance  (Rille)  as  late  as  sev- 
enteen days  after  the  last  crop  of  vesicles.  In  this  case,  which  ter- 
minated fatally,  a  post-mortem  examination  revealed  parenchymatous 
nephritis.  The  clinical  history,  however,  is  usually  that  of  mild  tubular 
nephritis.  While  death  has  seldom  occurred  from  this  complication, 
the  danger  of  the  kidneys  becoming  structually  impaired  is  apparent, 

286  Hutchinson  (J.),  quoted  by  J.  Lewis  Smith:   "Med.  and  Swrg.  Dis.  of  Infancy 
and  Childhood"  (Philadelphia,  1896),  p.  327. 

258  Howard:  In  Eustace  Smith's  "Diseases  of  Children"  (New  York,  1884);  see  also 
Brit.  Med.  Jour.,  1833,  i,  905. 

257  Crocker  (H.  Radcliffe) :  London  Lancet,  May  30,  1885. 

288  Vierordt:  In  Pentzoldt-Stinzing's  "Handbuch  der  speciellen  Therapie  innerer 
Krankheiten,"  B.  1,  S.  187  (see  von  Jiirgensen). 

^Loekwood  (W.  F.):  Arch.  Pediat.  (New  York,  1897),  xiv,  680-683. 

260  Silver  (L.  M.):  Ibid. 

281  Ploc  (K.):  Casop.  16k.  cesk.   (V.  Praze,  1898),  xxxvii,  84-86. 

282  Andrew:    "Clinical  Society's  Transactions"  (London,  1890),  xxiii,  p.  79. 
288  Henoch:  Berliner  klin.  Woch.,  No.  2,  January  14,  1884. 

284  Rille:  Ibid. ;  also  in  Wiener  klin.  Woch.,  1889,  and  in  Deutsche  med.  Woch.,  1891. 

285  Janssen:   Nedrl.  Tijdschr.,  1884,  B.  20,  S.  223. 

288  Openheim:    Berliner  klin.  Woch.,  December  26,  1887. 

287  Hogyes:    "Jahrbuch  fur  Kinderh.,  N.  F.,"  B.  23,  S.  337. 

288  Rasch:   Tijdskr.  for  praktisk  med.,  1884,  S.  68. 


VARICELLA.  163 

and  the  necessity  of  examining  the  urine  in  all  cases  of  varicella  can- 
not, therefore,  be  too  strongly  urged. 

Pneumonia  has  been  reported  by  Rille  and  Powell,269  pleurisy  and 
synovitis  by  Semtschenko,270  London,  Perret,  and  others;  simple  gen- 
eralized oedema  by  Starck,271  scleroderma  en  plaques  by  Bouvy,272 
scrofulo-tuberculosis  of  the  skin  by  Foulard,273  and  acute  tuberculosis 
of  the  lungs  by  Eustace  Smith.274  For  a  further  account  of  the  com- 
plications of  varicella,  together  with  a  carefully  prepared  bibliography, 
the  reader  is  referred  to  better's  article  in  the  Archiv  fur  Kinderheil- 
kunde,  xxx,  1900. 

PATHOLOGY. 

The  superficial  position  of  the  lesion  of  the  skin  in  varicella,  which 
is  covered  by  the  thinest  layer  of  epithelium,  is  constant.  This  char- 
acteristic feature  led  to  its  early  recognition  as  a  distinct  disease,  and 
the  term  crystalli,  applied  to  it  by  Guido  Guidi  ("Vidus  Vidius")  and 
Ingrassias,  clearly  indicates  that  they  were  familiar  with  its  develop- 
ment. 

The  changes  which  take  place  in  the  formation  of  the  vesicle  are 
essentially  as  follow:  There  is,  first,  a  slight  dilatation  of  the  super- 
ficial capillaries  in  the  papillary  layer  of  the  derma,  which  is  soon  fol- 
lowed by  an  exudation  of  serum.  This  is  never  so  abundant  as  in 
variola,  but  gives  rise  to  the  mild  grade  of  oedema  that  may  be  detected 
in  the  erythematous  macules. 

The  rapid  development  of  the  vesicle  beneath  the  superficial  layers 
of  the  epidermis  leads  to  the  degeneration  and  liquefaction  of  the 
epithelial  cells,  and  the  destruction  of  the  delicate  septa,  while  as  it 
develops,  there  is  seen,  not  uncommonly,  a  bright-red  zone  just  about 
the  outer  margin,  due  to  the  dilatation  of  the  superficial  vessels.  The 
contents  of  the  vesicle,  first  clear,  become  cloudy  and  opaque  after  the 
second  or  third  day,  owing  to  the  addition  of  cellular  elements;  they 
rarely  become  purulent. 

Unlike  the  lesion  in  variola,  there  are  commonly  no  cellular  septa 
present,  though  in  certain  instances  they  may  be  found. 


»"  Powell  (H.  H.):  "Internal.  Clinics"  (Philadelphia,  January,  1897),  vol.  iv,  p.  49. 

270  Semtschenko,  "Jahrbuch  fur  Kinderh.,  N.  F.,"  B.  25,  S.  171. 

271  Von  Starck:  Deutsches  Arch.  f.  klin.  Med.  (Leipzig,  1896),  Ivii,  448. 

272  Bouvy  (L.):   Jour,  de  clin.  et  de  theYap.  inf.  (1898),  vi,  486-489. 
278  Foulard  (M.  H.):  Ann.  de  derm,  et  de  la  syph.  (1896),  vll,  p.  362. 
274  Smith  (Eustace):  "Disease  in  Children"  (New  York,  1884),  p.  49. 


164  THE   ACUTE    EXANTHEMATA. 

The  changes  which  take  place  are  confined  wholly  to  the  epi- 
dermis. The  vesicles  contain  granular  fibrin,  a  moderate  cellular  exu- 
date,  cellular  debris,  and  serum;  this  differs  markedly  from  the  exudate 
in  variola,  which  is  usually  very  rich  in  cells,  especially  plasma-cells. 
The  pock  in  varicella  is  shallow,  rarely  involving  the  papillae  of  the 
cutis,  and  as  its  contents  are  absorbed  the  superficial  covering  is  cast 
off  in  the  form  of  a  brownish  scab,  sometimes  with  marked  pigmenta- 
tion, but  no  resulting  scar.  The  occurrence  of  a  scar  following  the 
varicella  lesion  is  occasionally  seen. 

ETIOLOGY. 

The  predisposing  causes  of  varicella  are  as  little  understood  as  are 
those  of  other  diseases  of  this  important  group.  Unlike  them  it  is  seen 
throughout  the  whole  year,  and  is  less  epidemic  in  character.  In  large 
cities  there  are  usually  sporadic  cases  at  all  times,  while  epidemics  occur 
at  frequent,  though  irregular,  intervals.  They  are  more  noticeable 
during  the  spring  and  fall,  and  especially  at  the  opening  of  schools 
and  kindergartens.  Insanitary  surroundings  act  as  predisposing  fac- 
tors, and  frequently  determine  both  the  severity  of  the  disease  and  the 
complications  which  arise.  It  was  formerly  thought  that  varicella 
could  not  be  inoculated.  Thus,  Heberden  in  150  cases,  as  well  as 
Vetter275  and  Fleischmann,276  obtained  negative  results.  Thomas's 
experiments  were  likewise  unsuccessful,  as  were  those  of  Heim.277 
Hesse  failed  in  87  inoculations,  while  in  17  he  produced  some  local 
disturbance  at  the  seat  of  inoculation,  and  in  9  the  inoculation  was 
followed  by  a  general  eruption  (Thomas).  In  this  country  J.  Lewis 
Smith278  inoculated  the  contents  of  varicella  vesicles  in  children  who 
had  never  had  the  disease,  with  negative  results.  The  present  writer 
has  inoculated  the  clear  serum  taken  from  varicella  vesicles  without 
ever  being  able  to  produce  the  disease.  On  the  other  hand,  Steiner279 
inoculated  10  children,  in  8  of  whom  the  disease  appeared  in  a  typical 
form.  This,  so  far  as  I  am  aware,  is  the  only  instance  of  successful 
inoculation.  It  is  extremely  doubtful,  therefore,  whether  varicella  is 
contagious  in  the  sense  that  variola  and  syphilis  are. 

275  Vetter,  Archiv  der  Heilkunde  (1860),  B.  1,  S.  286;  and  in  Virchow's  Archiv 
(1864),  B.  31,  S.  400. 

278  Fleischmann  (L.):  Archiv  fur  Derm,  und  Syph.  (1871),  B.  3,  S.  498. 

277  Heim:  Loc.  cit. 

278  Smith  (J.  Lewis):  "Med.  and  Surg.  Diseases  of  Infancy  and  Childhood"  (Phila- 
delphia, 1896),  p.  326. 

279  Steiner:  Wiener  med.  Woch.,  1875. 


VARICELLA.  165 

Its  infectious  nature  has  long  since  been  known,  and  Heberden 
regarded  varicella  as  being  as  infectious  as  variola.  Its  infectious  prop- 
erty, however,  is  short  lived,  and  does  not  cling  to  clothing;  nor  does 
it  remain  about  apartments  so  long  as  that  of  variola,  scarlatina,  or 
even  rubeola.  The  contagium,  like  others  of  this  class,  probably  gains 
access  through  the  air-passages;  in  fact,  from  our  present  knowledge 
this  seems  to  be  the  only  avenue  patent  to  its  invasion.  Direct  ex- 
posure from  person  to  person  is,  therefore,  usually  necessary,,  and  un- 
doubtedly this  is  the  common  mode  of  spreading  the  disease.  Unlike 
variola  and  other  affections  of  this  group,  age  plays  an  important  etio- 
logical  role.  It  is  essentially  a  child's  disease,  whereas,  with  the  pos- 
sible exception  of  scarlet  fever  and  rubella  after  middle  life,  it  has 
been  shown  that  the  exanthemata  are  communicated  with  equal  facility 
from  early  childhood  to  old  age.  During  a  period  of  twenty  years  in 
which  the  present  writer  has  been  occupied  in  studying  eruptive  dis- 
orders, not  a  single  instance  has  occurred  in  which  varicella  appeared 
after  the  fifteenth  year.  While  unwilling  to  believe  that  varicella  never 
occurs  after  puberty,  yet  this  experience  does  not  seem  to  be  in  any  way 
unique.  Hutchinson  (loc.  cit.,  p.  229),  with  the  abundant  clinical 
material  in  eruptive  diseases  which  London  affords,  has,  he  thinks, 
seen  it  once  or  twice  about  the  age  of  twenty,  and  remarks  that  a 
"point  of  great  interest  in  varicella  is  the  almost  absolute  immunity  of 
adults."  Thomas  (loc.  cit.,  p.  8)  says:  "Varicella  is  a  disease  of  child- 
hood, and  attacks  by  preference  young  children,  and  even  sucklings. 
In  children  over  ten  years  of  age  attacks  are  infrequent,  and  I  never 
saw  an  adult  suffering  from  varicella."  According  to  Graham,280  it  is 
seldom  seen  after  ten  years  of  age,  and  Eustace  Smith  (loc.  cit.,  p.  48) 
begins  his  article  with  the  statement  that  "Chicken-pox  is  seldom  seen 
except  in  young  subjects,  and  attacks  by  preference  children  aged  from 
two  to  six  years."  This  is  in  accord  with  Bohn,  who  has,  in  one  in- 
stance only,  encountered  it  in  the  sixteenth  year.  Von  Jiirgensen  says 
it  is  a  disease  which  probably  pertains  entirely  to  childhood,  and  rarely 
attacks  any  above  ten  years  of  age.  Kinsman,281  in  an  experience  with 
numerous  epidemics  covering  a  period  of  over  thirty  years,  is  positive 
that  he  has  never  seen  a  case  of  chicken-pox  in  an  adult.  On  the  other 
hand,  Gregory  has  met  with  7  instances  of  varicella  in  adult  females, 


280  Graham  (J.  E.):  "Varicella,"  in  Morrow's  "System  of  Dermatology,"  etc.  (New 
York,  1894),  vol.  in,  p.  98. 

281  Kinsman  (D.  N.):  "Discussion  on  the  Diagnosis  of  Small-pox."     "Transactions 
of  the  Ohio  State  Medical  Society,"  1899,  p.  108. 


166  THE   ACUTE    EXANTHEMATA. 

MacCombie  has  seen  it  in  7  persons  over  thirty  years  of  age.  J.  Lewis 
Smith  (loc.  cit.,  p.  326),  than  whom  few  men  have  had  a  larger  ex- 
perience, says:  "I  have  seen  one  adult  case,  which  I  recall  to  mind,  and 
Professor  Flint  states  that  he  has  also  observed  varicella  in  the  adult; 
but  its  occurrence  at  this  time  of  life  is  rare."  Finally,  Osier  says  it 
is  rarely  seen  in  adults. 

It  seems,  therefore,  established  that  varicella  finds  only  in  child- 
hood a  suitable  soil  for  development;  that,  with  puberty,  immunity  is 
acquired,  and,  while  there  are  exceptions  to  this  rule,  they  are  so  infre- 
quent as  to  be  regarded  as  anomalous,  and  in  no  way  invalidating  the 
most  constant,  as  well  as  the  most  characteristic,  feature  of  the  disease. 

Varicella,  then,  may  be  encountered  from  one  or  two  months  after 
birth  to  puberty,  and  in  asylums  and  similar  institutions  most  cases 
occur  between  the  ages  of  two  and  six  years,  while  in  private  families 
children  often  escape  until  a  later  period,  which  varies  from  three  to 
twelve  years. 

It  is  also  pretty  well  established  that  second  attacks  may  occur, 
and  Gerhardt282  has  seen  three  attacks  of  varicella  in  the  same  child. 
Second  attacks  are  extremely  infrequent,  however,  and  in  this  respect 
the  disease  probably  does  not  differ  from  variola,  rubeola,  and  other 
affections  which  are  self-protective. 

DIAGNOSIS. 

The  distinguishing  features  of  varicella  are:  (a)  Its  mild  pro- 
dromal symptoms,  which  may  be  wholly  absent,  (b)  The  appearance  of 
the  eruption  on  the  trunk,  where  it  is  usually  more  abundant  than  on 
the  face  or  hands,  (c)  The  multiform  character  of  the  eruption,  its 
superficial  position,  comparable  to  drops  of  water  sprinkled  over  the 
skin,  and  its  appearance  on  the  same  region  in  successive  crops,  (d) 
Its  mild  constitutional  symptoms  and  short  duration,  the  disease 
usually  terminating  within  from  five  to  fourteen  days,  (e)  Varicella 
is  mildly  infectious  and  always  gives  rise  to  a  like  disease. 

With  the  exception  of  the  last  mentioned,  these  cardinal  features 
have  been  duly  considered,  and  at  this  late  day  it  is  not  thought  neces- 
sary to  enter  into  a  discussion  as  to  the  grounds  for  describing  it  as  a 
separate  affection  and  in  no  sense  related  to  variola.  Those  who  desire 
a  full  discussion  of  this  subject  may  find  it  in  many  of  the  works  to 
which  reference  has  already  been  made. 

282  Gerhardt  (loc.  cit.). 


VARICELLA.  167 

The  points  of  differential  diagnosis  between  varicella  and  variola, 
the  disease  to  which  it  bears  the  strongest  resemblance,  will  be  found 
under  the  latter  disease.  The  disease  next  to  variola  with  which  vari- 
cella is  sometimes  confounded  may  be  mentioned: — 

Impetigo. — When  the  case  is  seen  late  in  its  course,  or  after  the 
rupture  of  some  of  the  vesicles;  the  diagnosis  between  chicken-pox  and 
impetigo  may  not  easily  be  made.  What  was  said  under  variola  in 
this  connection  applies  equally  to  varicella.  It  should  be  remembered 
that  impetigo  usually  appears  on  the  face,  especially  about  the  mouth 
and  nose;  next  in  frequency  on  the  hands;  and  is  clearly  the  result  of 
inoculation  from  one  region  to  another.  This  is  quite  unlike  the  de- 
velopment of  the  varicella  exanthem.  Again,  in  impetigo  the  lesions 
extend  at  the  periphery  in  the  form  of  a  bullous  ring,  and  seldom  pre- 
sent the  prominent,  tense,  bead-like,  transparent  vesicles  of  chicken- 
pox.  The  course  of  the  two  diseases  is  quite  dissimilar;  impetigo  is 
progressive  and  of  much  longer  duration,  often  lasting  weeks  or  even 
months,  while  chicken-pox  remains  but  a  few  days. 

Finally,  impetigo  is  contagious  and  never  infectious,  while 
chicken-pox  can,  with  difficulty,  be  successfully  inoculated.  Impetigo 
is  common  after  puberty,  while  chicken-pox  seldom  occurs  later  than 
from  ten  to  fourteen  years  of  age. 

PROGNOSIS. 

It  has  been  observed  that  the  course  of  varicella  is  largely  in- 
fluenced by  the  presence  or  absence  of  healthful  surroundings,  and  that 
the  previous  condition  of  health  influences  in  a  high  degree  the  ap- 
pearance of  complications  and  sequelae.  It  therefore  follows  that  with 
ordinary  care,  in  well  appointed  dwellings,  and  without  any  strong  pre- 
disposition to  disease,  the  prognosis  in  varicella  is  invariably  favorable. 
Trousseau  (loc.  cit.,  p.  136)  expresses  it  in  unmistakable  terms  when  he 
says:  "No  physician  has  ever  seen  a  patient  die  of  chicken-pox,  though, 
of  course,  there  may  be  a  fatal  issue  from  some  complications  inde- 
pendent of  the  exanthematous  fever."  In  asylums  and  the  wards  of 
hospitals,  delicate,  strumous  children  occasionally  develop  serious  com- 
plications, or  an  anasmic  condition  may  follow  an  attack  of  varicella. 
This  has  been  ably  set  forth  by  Walsh,283  who  found  tuberculosis, 
anaemia,  etc.,  induced  by  an  attack  of  chicken-pox  in  an  orthopaedic 


283  Walsh  (J.  J.):  Ther.  Gaz.  (Detroit,  1896),  3,  s.,  xii,  657-660. 


168  THE    ACUTE    EXANTHEMATA. 

ward.    These  must  be  regarded  as  rare  exceptions,  and  of  all  infectious 
diseases  of  childhood  varicella  is  the  least  fatal. 

TREATMENT. 

In  general,  prophylactic  treatment  is  uncalled  for  in  varicella.  It 
is  not  expedient,  however,  needlessly  to  expose  children  to  the  disease, 
and  especially  those  who  are  delicate  or  enfeebled  from  any  cause,  or 
those  in  whom  struma,  rachitis,  or  a  strong  predisposition  to  tuber- 
culosis exists. 

After  recovery  the  rooms  .should  be  aired,  and,  when  thought 
desirable,  may  be  fumigated,  before  other  children  are  allowed  to  enter. 
The  disease  itself  calls  for  no  special  treatment,  although  it  is  advisable 
to  keep  the  patient  within  doors  and  in  bed  during  any  marked  febrile 
disturbance.  Light  diet  and  a  well  ventilated  room  are  to  be  recom- 
mended in  all  cases.  Sometimes  mild  antifebrile  measures  are  indicated, 
and  such  other  treatment  may  be  given  as  the  occasion  demands.  When 
an  anaemic  state  follows,  change  of  air  or  removal  into  the  country  is 
advisable,  together  with  nourishing  and  easily  digestible  food.  Some- 
times vegetable  bitters,  iron,  and  codliver-oil  are  useful.  The  local 
treatment  is  usually  of  more  importance.  Cleanliness  should  be  scrupu- 
lously maintained.  The  underclothing  should  be  changed  at  frequent 
intervals  and  the  body  bathed;  the  finger-nails  should  be  cut  short; 
and  a  nail  brush,  with  one  of  the  antiseptic  solutions  mentioned  at  the 
end  of  the  volume,  used  daily.  If  pus  forms  or  the  vesicles  rapidly 
enlarge,  they  should  be  opened  and  the  sacks  flushed  out  with  a  solu- 
tion of  boric  acid  or  some  other  disinfectant  (Nos.  2  or  3  in  "Ad- 
dendum"). In  case  gangrene  occurs,  a  stimulating  regimen  and  strict 
local  asepsis  is  imperative.  For  this  purpose  it  is  necessary  to  remove 
all  debris  by  means  of  a  curette,  and  the  cavity  should  be  packed  or 
otherwise  dressed  with  a  solution  of  corrosive  sublimate  (1  to  1000). 
On  the  face,  when  the  vesicles  become  yellow,  they  should  be  opened 
and  some  bland  antiseptic  dressing  applied  (No.  5  in  "Addendum"). 


CHAPTER  V. 

SCARLATINA. 

(Scarlet  fever;  German,  scharlach;  French,  scarlatine; 
Italian,  scarlattina  ;  Spanish,  escarlatinit ;  Danish  and  Norwegian, 
skarlagensfeber ;  Dutch,  scharlakenkoorts ;  Latin,  febris  rubra.) 

ALTHOUGH  scarlet  fever  had  been  studied  and  described  by  many 
of  the  earlier  observers,  and  by  some  of  them  most  accurately  por- 
trayed (see  pages  22  to  27),  it  was  not  until  the  appearance  of  Syden- 
ham's  work  late  in  the  seventeenth  century  (1670-74)  that  it  was  first 
assigned  a  place  as  a  distinct  disease  among  the  acute  exanthemata. 
Not  until  late  in  the  eighteenth  century  was  it  sharply  differentiated 
from  measles  by  Withering,  in  1793  (loc.  cit.},  prior  to  his  time  great 
confusion  having  existed  between  the  three  diseases:  measles,  scar- 
latina, and  diphtheria.  Even  so  late  as  1875  Gerhardt284  raised  the 
question  as  to  whether  what  we  call  scarlatina  was  not  rather  a  symp- 
tom-complex, than  a  disease  sui  generis.  Since  the  end  of  the  seven- 
teenth century  scarlet  fever  has  been  present,  more  or  less  constantly, 
throughout  the  northwestern  countries  of  Europe,  while  Asia  and 
Africa  have,  with  certain  local  exceptions,  remained  quite  as  constantly 
free  from  it.  Egypt,  India,  Burmah,  Ceylon,  and  Japan  are  protected 
in  some  way  against  outbreaks  of  scarlatina  in  an  epidemic  form,  iso- 
lated and  small  groups  of  cases  occurring  from  time  to  time,  due  to 
importation. 

In  North  America  the  disease  first  appeared  in  Massachusetts  in 
1735,  and  from  this  point  spread  slowly,  invading  the  New  England 
States  along  the  sea-coast,  and  appearing  in  New  York  State  in  1746. 
Throughout  the  last  half  of  the  eighteenth  century  scattered  out- 
breaks of  scarlatina  occurred  along  the  sea-board,  but  these  were  infre- 
quent, and  it  was  not  until  1791  that  it  extended  inland,  reaching 
Canada  early  in  the  nineteenth  century.  From  this  time  scarlet  fever 
has  been  almost'  constantly  present  in  epidemic  form  throughout  the 
larger  cities  of  North  America.  South  America  remained  apparently 
free  from  the  disease  until  1830,  since  which  time  it  has  become  scat- 
tered over  the  continent,  and  frequently  appears  in  epidemics  of  vary- 
ing malignancy.  In  Australia  the  presence  of  scarlatina  in  epidemic 
form  is  uncommon. 


284  Gerhardt  (C.):   "Jahrbuch  fur  Kinderh.,  N.  F.,"  vol.  ix,  p.  322. 

(169) 


170  THE   ACUTE    EXANTHEMATA. 

DEFINITION. 

Scarlet  fever  is  an  acute,  specific,  contagious,  and  infectious  febrile 
disease,  characterized  by  its  sudden  onset,  which  is  commonly  ushered 
in  by  headache,  sore  throat,  and  vomiting,  together  with  a  very  rapid 
pulse,  a  sharp  rise  of  temperature,  and  by  the  appearance  of  an  ery- 
thematous  rash,  seen  usually  by  the  second  day  upon  the  upper  thorax 
and  neck,  which  then  spreads  rapidly  over  the  greater  part,  or  the 
entire  surface,  of  the  body,  and  is  followed  after  its  disappearance, 
by  desquamation.  It  is  almost  constantly  associated  with  a  more 
or  less  intense  inflammation  of  the  pharynx  and  with  enlargement 
of  the  neighboring  lymphatic  glands,  and  is  further  marked  by  a 
grave  tendency  to  certain  complications.  One  attack  usually  confers 
immunity. 

Among  the  contagious  and  eruptive  fevers  none  presents  so  many 
varied  types  as  scarlet  fever,  ranging,  as  it  does,  from  the  mildest  form, 
SCARLATINA  SIMPLEX,  or  BENiGNA,  to  the  most  malignant  type,  SCAR- 
LATINA MALIGXA,  called  by  the  French  foudroyante.  Between  these 
two  extremes  we  find  an  almost  endless  variation  from  the  normal,  one 
shading  gradually  into  the  other;  so  that  any  sharp  differentiation  into 
groups  is  quite  impossible.  Clinically,  however,  we  may  distinguish 
three  types:  the  moderate,  or  mild;  the  severe;  and  the  malignant, 
or  cerebral,  form.  The  following  is,  perhaps,  an  even  better  classifica- 
tion: (a)  SIMPLE,  (6)  SEPTIC,  and  (c)  TOXIC,  to  which  might  well  be 
added  a  fourth  group,  including  the  anomalous  cases,  though  these 
may  be  placed  under  one  of  the  three  main  divisions,  as  variations, 
only,  from  a  given  type. 

SYMPTOMATOLOGY. 

As  in  small-pox  and  measles,  we  have  here  to  differentiate  the  sev- 
eral stages  of  the  disease,  which  may  be  classified  as  the  stages  of  in- 
cubation (stadium  incubatioms),  of  invasion  (stadium  prodromorum), 
of  eruption  (stadium  eruptionis),  and  of  desquamation  (stadium  des- 
quamationis). 

STAGE  OF  INCUBATION. — Much  difference  of  opinion  has  existed 
as  to  the  duration  of  the  period  of  incubation  in  scarlet  fever,  it  being 
necessarily  difficult  to  determine  with  exactness  the  length  of  time 
that  has  elapsed  between  exposure  to  the  disease  and  the  appearance  of 
the  symptoms.  This  stage  lasts  from  a  few  days  to  a  week,  with,  of 
course,  exceptions  in  which  the  period  of  incubation  may  be  short- 


SCARLATINA.  171 

ened  to  a  few  hours  or  may  exceed  the  above  limit  by  several  days. 
Eichhorst285  and  von  Leube286  give  it  as  from  four  to  seven  days. 

The  epidemic  which  broke  out  in  the  Canary  Islands  in  1873-75 
afforded  many  excellent  opportunities  for  a  careful  study  of  the  period 
intervening  between  exposure  and  the  appearance  of  the  symptoms. 
For  fifty-seven  years  prior  to  this  time  not  a  single  case  of  scarlet  fever 
had  been  known  to  exist  in  these  islands.  This  epidemic,  though  it 
could  not  be  definitely  proved,  originated  probably  in  the  Shetland 
or  the  Orkney  Islands.  Hoff2*7  found,  from  his  observations  at  the 
time,  that  in  this  epidemic  the  average  duration  of  the  period  of  in- 
cubation was  from  eight  to  nine  days,  with,  however,  certain  excep- 
tions. Petersen,288  during  the  same  outbreak,  noted,  in  those  cases  in 
which  he  could  accurately  determine  it,  an  incubation  of  from  nine 
to  eleven  days,  which  Lund289  was  able  to  confirm.  In  nine  cases 
quoted  by  him  it  was  as  follows: — 

Of     9  days'  duration,  1  case. 
"    10      "  5  cases. 

"    11      "  3      " 

Murchison,290  in  1864,  published  a  series  of  thirteen  cases,  in 

none  of  which  did  the  period  of  incubation  go  beyond  six  days,  as  fol- 
lows:— 

Of  less  than  24  hours'  duration,  2  cases. 

"       "        "      31  \     "  1  case. 

"       "        "      36       "  1      " 

"       "        "      40       "  "  1      " 

"       "        "        3  days'  2  cases. 

"      "        "        3£     "  1  case. 

"       "        "        4       "  "1      " 

"      "        "        5       "  3  cases. 

"       "        "        6       "  "1  case. 

Later,  in  1878,  the  same  observer291  published  a  series  of  seventy- 
five  cases,  in  not  one  of  which  the  period  of  incubation  exceeded  that 
noted  above. 


285  Eichhorst:  "Specielle  Pathologie  und  Therapie"  (Leipzig,  1897),  vol.  iv,  p.  231. 

286  Von  Leube:  "Specielle  Diagnose  der  Inneren  Krankheiten"   (Leipzig,  1898),  p. 
413. 

287  Hoff :    "Sundhedskollegiets   Aarsberetning,"    1876.     Quoted   by   von   Jiirgensen, 
"Acute  Exantheme,  Scharlach,  Rotheln,  Varicellen"   (Wien,  1896),  p.  7. 

288  Ibid.,  p.  8. 

289  Ibid. 

290  Murchison   (C.):  "Contributions  to  the  Etiology,  Pathology,  and  Treatment  of 
Scarlet  Fever."    The  London  Lancet,  1864,  vol.  ii,  pp.  481-485. 

291  Murchison  (C.):  "Observations  on  the  Period  of  Incubation  of  Scarlet  Fever." 
"Clinical  Society's  Transactions"  (London,  1878),  vol.  xi,  pp.  238-265. 


172  THE    ACUTE    EXANTHEMATA. 

In  striking  contrast  with  this  careful  series  is  the  following 
equally  valuable  observation  by  E.  Hagenbach-Burkhardt,292  who,  in 
a  series  of  58  cases  in  which  he  was  able  to  ascertain  the  duration  of 
the  period  of  incubation,  found  that  in  38  it  exceeded  six  days,  as  fol- 
lows:— 

Of  less  than     7   days'    duration,   3  cases. 

«       .<  8       «  4      « 

"  "  "  9  "  "2   " 

"  "  "  10  "  1  case. 

"  "  "  11  "  5  cases. 

"  "  "  12  "  1  case. 

"  "  •  "  13  4  cases. 

"  "  "  14  "  2   " 

"  "  "  15  "  5   " 

"  "  "  17  "  2   " 

"  "  "  18  "  "     1  case. 

"  "  "  19  "  2  cases. 

Of  over  20  "  6   " 

Hagenbach  gives  these  cases  with  some  reserve,  assuming  them  to 
be  as  nearly  accurate  as  such  observations  can  be,  and  admits  that 
during  what  appears  to  be  a  long  period  of  incubation  one  may  be 
deceived  by  a  subsequent  indirect  infection.  But  it  is  surely  impossible 
that  in  such  a  series  as  quoted  above  indirect  infection  could  play  any 
important  part.  It  is  clearly  shown  from  these  instances  that,  in  ex- 
ceptional cases,  the  duration  of  incubation  may  be  prolonged  consid- 
erably beyond  the  average  time. 

Condition®  which  Modify  the  Stage  of  Incubation.  —  It  has  long 
been  recognized  that  certain  conditions  strikingly  modify  the  length 
of  the  period  of  incubation,  increasing  at  the  same  time  the  indi- 
vidual's susceptibility  to  the  disease.  The  existence  of  a  wound  in  the 
person  exposed  seems  to  offer  a  ready  entrance  to  the  poison,  and  in 
the  majority  of  such  cases  the  period  of  incubation  is  much  short- 
ened, as  in  scarlet  fever  following  tracheotomy  wounds  in  children 
(Hagenbach,  loc.  cit.,  p.  115)  or  in  cases  of  ordinary  surgical  and  acci- 
dental wounds.  A  notable  exception  to  this  latter  statement  is  the 
case  of  von  Leube's  (loc.  cit.,  p.  413),  who,  while  making  a  post-mor- 
tem examination  upon  a  body  dead  of  scarlet  fever,  injured  himself 
slightly  in  the  index  finger,  and  eleven  days  afterward  developed  a 


202  Hagenbach-Burkhardt   (P.):    "Ueber   Spitalinfectionen."     "Jahrb.    f.    Kinderh., 
N.  F.,"  vol.  xxiv,  pp.  105  et  seg. 


SCARLATINA.  173 

typical  attack  of  scarlatina.  Johannessen293  has  further  attempted  to 
demonstrate  that  the  duration  of  the  stage  of  incubation  is  affected 
by  the  virulence  of  the  epidemic.  The  milder  the  type  of  the  pre- 
vailing epidemic,  the  longer;  while,  the  more  malignant,  the  shorter 
is  the  period  of  incubation. 

In  many  instances,  when  exposure  has  occurred  during  confine- 
ment, or  the  puerperium,  in  addition  to  the  increased  susceptibility, 
the  average  duration  of  incubation  has  been  shown  to  be  shorter  than 
in  the  normal  individual. 

As  a  rule,  during  the  period  of  incubation  subjective  symptoms 
are  absent,  the  first  indications  of  the  disease  appearing  during  the 
stage  of  invasion. 

SCARLATINA  SIMPLEX. 

ACTUAL    ATTACK. 

PERIOD  OF  INVASION,  OR  PRODROMAL  STAGE  (Stadium  Prodro- 
morum). — The  period  of  invasion  in  scarlatina  is  usually  of  very  short 
duration,  and  represents  that  period  immediately  preceding  the  actual 
attack.  During  this  time  some  vague  and  slight  subjective  symptoms 
may  be  complained  of  by  the  individual,  lasting  commonly  twenty- 
four  hours  or  less,  though  exceptionally  extending  over  several  days 
(Mayr294).  Eichhorst  (loc.  cit.,  p.  232)  gives  the  duration  as  from 
twenty-four  to  forty-eight  hours:  Henoch,293  twenty-four  hours, 
though  exceptionally  thirty-six  to  forty-eight  hours.  By  many  ob- 
servers it  is  held  that  the  intensity  of  the  initial  symptoms  bears  an 
intimate  relation  to  the  severity  of  the  infection.  While  this  may  be 
true  in  a  certain  number  of  cases,  it  is  by  no  means  constant.  In 
Henoch's  opinion  (loc.  cit.},  no  accurate  judgment  as  to  the  mildness 
or  severity  of  the  attack  can  in  all  instances  be  formed  from  the  early 
symptoms. 

As  a  rule,  the  onset  is  sudden,  occurring  in  an  individual  ap- 
parently well,  in  whom,  previous  to  the  appearance  of  the  first  active 
symptoms,  there  has  been  no  indication  of  the  threatened  infection. 
This  is  more  often  true  in  the  case  of  children  than  of  adults,  though 
not  infrequently  at  either  age  slight  anorexia,  listlessness,  or  irritability 

283  Johannessen  (Axel):  "Die  Epidemische  Verbreitung  des  Scharlachflebers  in 
Norwegen"  (Christiania,  1884),  p.  166. 

294  Mayr:   "Scarlatina,"  in  Hebra's  "Diseases  of  the  Skin."     "Sydenham  Society's 
Trans."   (London,  1866),  vol.  i,  p.  190. 

295  tienoch  (Ed.):  "Vorlesungen  ueber  Kinderkrankh."  (Berlin,  1897),  p.  643. 


174  THE    ACUTE    EXANTHEMATA. 

may  precede  the  earliest  signs  of  the  disease.  Children  may  at  times 
complain  of  a  tickling  sensation  in  the  throat  and  vague  pains  through- 
out the  back  and  limbs.  In  adults  the  early  headache  is  more  pro- 
nounced; "the  subjective  symptoms  in  the  throat  may  amount  to  actual 
soreness,  and  there  may  be  great  languor  and  dullness  preceding  the 
first  active  indications  of  the  attack.  In  the  vast  majority  of  cases, 
however,  the  disease  is  ushered  in  abruptly  by  headache,  sore  throat, 
and  a  rapid  rise  of  temperature;  while  in  children,  in  addition  to  these 
three  cardinal  symptoms,  the  onset  is  almost  constantly  associated  with 
vomiting,  which  may  or  may  not  be  repeated.  Occasionally,  chilly 
sensations,  more  rarely  a  true  chill,  precede  the  sudden  rise  of  tem- 
perature; and,  in  young  children,  convulsions  very  commonly  mark 
the  beginning  of  the  disease.  At  other  times  a  severe  diarrhoea  is  the 
first  symptom;  or,  again,  a  sudden  attack  of  syncope,  and  in  rarer 
instances  one  or  more  epileptiform  attacks  mark  the  onset.296 
Thomas297  states  that  vomiting  associated  with  convulsions  occurs 
more  frequently  as  an  initial  symptom  of  scarlatina  than  of  any  other 
disease  of  childhood,  excepting  only  small-pox  and  pneumonia. 

With  the  appearance  of  these  early  symptoms  the  temperature 
suddenly  rises,  reaching  102°  F.  (38.8°  C.)  or  over  by  the  evening  of 
the  first  or  early  on  the  second  day,  if,  as  so  often  happens,  the  attack 
has  developed  late  in  the  afternoon  or  evening.  The  pulse  is  full  and 
very  rapid  (120  to  140  beats  to  the  minute);  the  younger  the  child, 
the  more  rapid,  as  a  rule,  is  the  pulse-rate.  This  rapidity  of  the  pulse 
very  frequently  persists  throughout  the  course  of  the  attack  and  usu- 
ally shows  a  marked  disproportion  to  the  height  of  the  fever:  a  point 
upon  which  Trousseau298  laid  great  stress.  Within  the  first  few  hours 
the  submaxillary  lymphatic  glands  at  the  angle  of  the  jaw  are  swollen, 
and  frequently  slightly  tender  on  palpation.  The  tongue  is  coated  with 
a  grayish-white  fur  of  varying  thickness,  while  the  edges  and  tip  are 
reddened,  and  the  papillae  remaining  free  from  this  exudate  early  be- 
come prominent:  a  point  of  no  little  diagnostic  value.  There  is  in- 
creased thirst.  The  mucous  membrane  of  the  mouth  is  reddened;  the 
pharynx,  the  tonsils,  and  the  uvula  are  injected;  and  prostration  is 
more  or  less  marked,  depending  upon  the  severity  of  the  infection. 
Upon  examination  of  the  throat  at  this  stage,  the  early  evidences  of 


298  Henoch  (loc.  cit.). 

297  Thomas  (Louis):  "Scarlatina,"  in  von  Ziemssen's  "Cyclopaedia  of  the  Practice 
of  Medicine"  (Transl.,  New  York,  1875),  vol.  ii,  p.  238. 

298  Trousseau's  "Clinical  Medicine"   (Transl.,  Phila.,  1873),  p.  141. 


SCAKLATINA. 


175 


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Scarlatina  Simplex.    Normal,  Uncomplicated  Course.     (Writer's  Case.) 


176  THE   ACUTE    EXANTHEMATA. 

the  eruption  are  seen  on  the  buccal  mucous  membrane,  though  they 
are  absent  in  those  cases  of  such  a  mild  type  that  the  throat  symptoms 
are  almost,  if  not  wholly,  wanting.  Monti299  has  called  especial  atten- 
tion to  the  early  appearance  of  the  enanthem  in  scarlatina,  which  is 
seen  late  on  the  first  or  early  on  the  second  day.  This  appears  as  a 
diffuse  mottled  reddening,  which,  beginning  commonly  upon  the  uvula, 
spreads  quickly  over  the  soft  and  hard  palates,  covering  the  pillars  of 
the  fauces,  and  finally,  the  mucous  membrane  of  the  cheeks,  but  not, 
as  a  rule,,  extending  on  to  the  post-pharyngeal  wall.  The  injection  of 
the  tonsils  is  marked,  the  follicles  on  their  surfaces  are  swollen  and 
prominent,  and  the  mouth  is  dry. 

The  clinical  picture  of  the  disease  at  this  time,  late  on  the  first  or 
early  on  the  second  day,  is  that  of  the  early  stage  of  an  acute  fever. 
In  adults  there  is  great  relaxation  and  lassitude.  Children,  as  a  rule, 
are  dull  and  apathetic,  showing  a  great  desire  to  be  left  undisturbed. 
They  may  be  restless  and  anxious,  and,  if  the  fever  be  high,  mild 
delirium  may  be  present  early  in  the  course  of  the  disease.  In  the 
severer  forms  this  cerebral  disturbance  is  much  more  pronounced,  and 
the  restlessness  and  delirium  may  be  extreme.  The  face  is  flushed,  the 
eyes  are  dull  and  heavy,  and  the  conjunctiva?  slightly  injected,  lacking, 
however,  the  active  catarrhal  inflammation  seen  in  measles.  Unless 
there  be  some  co-existing  trouble,  the  lungs  are  clear,  and  physical 
examination  reveals  nothing  except  as  described  above.  The  urine  is 
scanty  and  high  colored,  and  may,  if  the  fever  be  high,  contain  a  slight 
trace  of  albumin  from  the  first. 

STAGE  OF  ERUPTION  (Stadium  Eruptionis).  —  The  eruption  of 
scarlet  fever  presents  such  constant  variations,  both  as  regards  char- 
acter and  duration,  and  is  necessarily  so  modified  by  the  nature  of 
the  skin  upon  which  it  develops,  as  well  as  by  the  intensity  of  the 
infection,  that  it  is  impossible  to  ascribe  to  it  any  fixed  course  in  a 
single  given  type  of  the  disease.  As  a  rule,  it  develops  more  rapidly 
in  blonde  children  and  full-blooded  individuals  than  in  the  darker  skin 
of  brunettes  or  in  the  pale  and  anaemic.  The  warmth  of  the  bed- 
clothes and  crying  increase  the  intensity  of  the  eruption,  while  a  hot 
bath  will  frequently  heighten  the  color,  often  turning  a  pale  red  into 
a  bright  scarlet.  As  in  all  the  eruptive  fevers,  the  rash  is  more  pro- 
nounced over  those  areas  exposed  to  pressure  or  irritation,  as  the  nates 
and  back.  Upon  pressure  the  scarlet  blush  of  the  eruption  momen- 

289  Monti  (A.):  "Studien  ueber  das  Verhalten  der  Schleimhaute  bei  den  acuten 
Exanthemen."  "Jahrb.  f.  Kindh.,  N.  F.,"  vol.  vii,  pp.  227  et  seq. 


SCAKLATINA.  177 

tarily  pales,  only  to  return  with  the  removal  of  the  pressure.  This 
paling  of  the  eruption  is  not  seen,  of  course,  in  those  cases  in  which 
actual  haemorrhage  into  the  skin  has  occurred,  and  is  not  in  any  way 
characteristic  of  scarlet  fever. 

Eapidly  following  the  appearance  of  the  initial  symptoms  of  the 
stage  of  invasion  (usually  within  the  first  twenty-four  hours)  the  char- 
acteristic rash  is  seen  upon  the  neck  and  upper  thorax  in  the  sub- 
clavicular  region,  and  less  commonly  upon  the  small  of  the  back,  as 
a  diffuse,  bright-red  (scarlet)  blush,  which,  when  examined  more 
closely,  is  found  to  be  made  up  of  countless,  minute,  brightly  injected 
spots,  pin-point  in  size,  occupying  the  sites  of  the  hair-follicles,  closely 
studded  together,  and  separated  from  one  another  only  by  small  areas 
of  pale  skin. 

As  the  eruption  progresses  these  pale  areas  acquire  a  brighter 
erythematous  tinge,  giving  to  the  diffuse  redness  a  much  more  char- 
acteristic scarlet  hue,  while  there  may  develop  coincidently  a  slight 
oedema  of  the  skin.  The  rash  extends  rapidly  from  above  downward, 
spreading  in  a  few  hours  to  the  arms,  where  it  is  well  marked  about 
the  elbows;  and  in  the  course  of  twelve  to  twenty-four  hours — rarely 
longer — reaches  the  trunk  and  legs.  Upon  the  face,  in  contrast  to 
small-pox  and  measles,  the  true  scarlatinal  eruption  is  much  less 
marked,  and  is  seen,  as  a  rule,  only  upon  the  forehead  and  cheeks,  the 
latter  being  frequently  deeply  flushed  and  injected,  while  the  imme- 
diate neighborhood  of  the  nose  and  mouth  remains  free  from  the 
eruption  and  presents,  in  strong  contrast,  a  peculiar,  striking  pallor. 

Upon  the  dorsal  surface  of  the  hands  and  feet  the  eruption  is 
often  very  marked,  showing  characteristic  isolated  points  of  a  pro- 
nounced scarlet  tint,  while  the  palmar  and  plantar  surfaces,  though 
frequently  deeply  injected,  do  not  usually  show  the  true  punctate 
scarlatinal  rash.  Over  the  trunk  and  extremities  the  eruption  appears 
commonly  in  irregular  patches  of  varying  size  of  an  intense  scarlet 
color,  and  upon  the  latter  frequently  shows  a  tendency  to  occupy  the 
extensor,  rather  than  the  flexor,  surfaces. 

Usually  by  the  evening  of  the  second  or  the  third  day  the  rash 
has  reached  its  greatest-  extent  and  intensity,  covering  the  entire  body 
as  a  bright  scarlet  blush,  which  has  been  variously  described  as  of  the 
color  of  a  foiled  lobster,"  "raspberry-juice,"  etc.  With  slight  daily 
variations,  influenced  somewhat  by  the  rise  and  fall  in  temperature, 
the  rash  remains  at  its  maximum  for  from  one  to  three  days — excep- 
tionally longer.  Henoch  (loc.  cit.,  p.  645)  has  called  attention  to  the 


178  THE   ACUTE    EXANTHEMATA. 

remittent  intensity  of  the  eruption,  which  is,  as  a  rule,  more  pro- 
nounced in  the  evening  than  during  the  morning  hours,  and  has  noted, 
further,  a  change  from  day  to  day,  which  is  not  always  in  keeping 
with  the  variations  in  the  temperature-curve.  With  the  appearance 
and  extension  of  the  rash  the  general  symptoms  increase  in  severity. 
The  injection  of  the  pharynx  and  buccal  mucous  membrane  is  more 
intense.  The  tonsils  are  swollen  and  show  scattered  foci  of  exudate 
upon  their  surfaces;  the  pain  upon  swallowing  is  increased,  and  chil- 
dren may  even  complain  of  pain  extending  upward  toward  one  or  both 
ears.  After  the  second  day  the  tongue  gradually  loses  its  heavy  coat- 
ing, becoming,  however,  deeply  injected;  the  superficial  epithelium  is 
lost;  the  papillae  at  the  tip  and  along  the  margins  are  more  prominent, 
and,  by  the  time  all  the  symptoms  are  at  their  maximum,  usually 
presents  the  characteristic  "strawberry"  appearance,  the  "katzenzunge" 
of  the  German  writers  (see  Plate  XXX). 

The  submaxillary  lymph-glands  are  slightly  enlarged,  easily  pal- 
pable, and  more  or  less  tender  on  pressure.  The  temperature  may  con- 
tinue to  rise,  or  remain  at  its  original  mark  with  but  slight  daily 
variation,  as  a  rule,  for  from  three  to  six  days.  The  pulse-rate,  as 
previously  noted,  remains  markedly  increased,  and  out  of  all  propor- 
tion to  the  fever.  The  skin  is  tense,  hot,  and  dry,  and  the  urine  scanty 
and  high  colored.  From  the  second  to  the  fourth  day — in  many  cases 
even  earlier — the  rash  begins  to  fade,  disappearing,  as  a  rule,  in  the 
order  of  its  appearance;  and  at  once  an  improvement  in  all  the  symp- 
toms sets  in.  The  temperature  comes  down  slowly,  in  contrast  to  the 
abrupt  fall  seen  in  measles,  and  the  pulse  becomes  slower  and  of  better 
quality.  The  injection  of  the  pharynx  subsides,  the  tonsils  clear  up, 
the  pain  upon  swallowing  lessens,  the  appetite  returns,  and  the  child 
appears  brighter.  The  skin  becomes  cool  and  moist,  and,  excepting 
for  a  certain  loss  of  elasticity  and  a  slight  brownish-gold  pigmentation 
(more  marked  over  those  areas  where  the  eruption  was  most  pro- 
nounced), appears  natural.  Desquamation  commences,  and  by  the 
seventh  to  the  ninth  day  convalescence  has  been  established,  and  ad- 
vances to  complete  recovery  unless  interrupted  later  by  some  one  of 
the  dreaded  complications,  from  which  even  the  mildest  type  of  the 
disease  is  not  always  exempt. 

STAGE  OF  DESQUAMATION  (Stadium  Desquamationis). — The  des- 
quamation  of  the  skin  in  scarlatina  commonly  begins  over  those  areas 
on  which  the  rash  was  first  seen,  and  from  which  it  first  disappears, 
namely:  the  upper  thorax  and  neck,  proceeding  slowly  until  the 


PLATE  XXX. 


XXX 

SCARLATINA— showing  eruption  at  its  height,  with   "strawberry  tongue. 


JUm  RMcrtrn^t  aSons.M  !>','• 


PLATE  XXXI. 


X 


PH 


PLATE  XXXII. 


PLATE  XXXTT. 


Scarlatina,    showing   Desquamation.      (Through   the    Courtesy   of   Dr.    J.    F.    Schamberg.) 


SCARLATINA.  179 

process  has  included  the  entire  body,  in  many  instances  even  the  face 
and  head  not  escaping.  It  is  not  unusual  to  find  the  fine,  scaly  des- 
quamation  present  upon  the  upper  thorax  while  the  extremities  still 
show  distinct  traces  of  the  scarlatinal  rash.  The  character  of  the  des- 
quamation  in  scarlet  fever  varies  with  the  locality,  and  presents  two 
distinct  types.  Upon  the  neck,  face,  and  trunk  the  scales  of  the  epi- 
dermis are  small,  fine,  and  flaky,  closely  resembling  those  seen  in  mea- 
sles,— desquamatio  f-urfuracea  (see  Plate  XXXII);  while  upon  the  ex- 
tremities, and  particularly  about  the  hands  and  feet,  the  characteristic 
desquamation  is  best  observed.  The  epidermis  peels  off,  or  may  be 
stripped  off  in  shreds  of  varying  length,  at  times  forming  a  complete 
cast  of  a  finger,  and  in  rarer  instances  even  of  a  hand, — desquamatio 
membranacea  or  lamellosa.  The  presence  of  desquamating  epidermis 
of  this  character  about  the  hands  or  feet  is,  in  itself,  a  strong  proof  of 
the  previous  existence  of  scarlatina,  no  matter  what  the  history  may 
be.  The  duration  of  the  period  of  desquamation  varies  greatly,  and 
is  apparently  influenced  by  the  severity  of  the  infection,  as  evidenced 
by  the  intensity  of  the  eruption:  the  more  intense  the  latter,  the 
earlier  is  desquamation  established,  and  not  infrequently  it  lasts  longer 
than  in  those  cases  having  a  less  pronounced  rash.  It  always  persists 
longer  where  the  epidermis  is  thick,  as  about  the  hands  and  feet;  and 
just  so  long  as  a  single  flake  of  necrotic  skin  remains  the  patient  may 
be  a  source  of  contagion.  The  length  of  time  for  the  completion  of 
the  process  may  be  said  to  extend  from  six  to  eight  weeks:  in  many 
instances  it  is  shorter,  and  in  many  of  even  longer  duration.  The 
occurrence  of  repeated  desquamation  is  not  uncommon.  McCollom,300 
in  an  analysis  of  a  thousand  cases,  found  the  average  duration  of  this 
period  to  be  fifty  days,  and  has  further  noted  a  comparatively  small 
number  of  cases  of  secondary,  and  a  few  cases  of  tertiary,  desquama- 
tion. Instances  in  which  desquamation  has  occurred  four  and  even 
five  times  are  reported  in  literature. 

SEPTIC  SCARLET  FEVER.     (Scarlatina  Anginosa.) 

This  type  of  the  disease  is  characterized  by  the  severity  of  the 
initial  symptoms,  associated  with  early  and  marked  involvement  of 
the  pharynx  and  tonsils,  high  and  continued  fever,  and  profound  pros- 
tration. Cases  of  this  character  are  seen  more  commonly  in  children, 
though  adults  are  not  exempt. 

300  McCollom:   "Boston  City  Hospital  Reports,"  X  Series,  1889,  p.  32. 


180 


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URINE 

Scarlatina  Septica.  Excessive  Angina;  Active  Delirium  from 
Second  until  the  Morning  of  the  Fifth  Day.  On  Sixth  Day  Threatened 
Uremia,  Ursemic  Twitchings,  Respirations  Twelve  to  the  Minute, 
almost  Complete  Suppression  of  Urine.  Recovery.  (Writer's  Case.) 


SCARLATINA.  181 

From  the  first  the  headache  and  sore  throat  are  intense;  the  local 
inflammation  of  the  pharynx  develops  with  great  rapidity,  severe  pain 
and  difficulty  on  swallowing  being  early  and  prominent  symptoms. 

In  children  there  may  be  pronounced  cerebral  disturbance,  ex- 
treme restlessness,  convulsions,  or  mild  delirium;  while  at  other  times 
abrupt  and  violent  gastro-intestinal  symptoms,  with  severe  and  pro- 
longed vomiting,  usher  in  the  attack.  The  temperature  rises  suddenly 
to  105°  F.  (40.5°  C.),  or  higher;  the  pulse  becomes  very  rapid  (140 
to  160  to  the  minute),  of  small  volume,  and  at  times  can  only  be 
counted  with  great  difficulty.  The  thirst  is  extreme,  while  the  water 
taken  may  be  immediately  ejected.  The  pharynx  and  tonsils  are 
deeply  injected,  and  early  in  the  course  of  the  disease  the  latter  become 
acutely  swollen,  showing  here  and  there  scattered  foci  of  exudate  upon 
their  surfaces.  The  skin  is  very  hot,  tense,  and  dry,  and  often  sensitive 
to  the  touch.  The  scanty,  concentrated  urine  at  this  time  almost  in- 
variably contains  albumin. 

Usually  within  a  few  hours  after  the  onset  the  rash  appears,  and 
in  this  type  of  the  disease  shows  great  variations.  It  may  be  seen  first 
upon  the  chest  or  neck  as  small  or  larger  faintly  scarlet  patches  of  an 
irregular  outline,  which  last  but  a  short  time,  disappearing,  only  to 
reappear  later  upon  the  trunk,  back,  or  extremities.  In  many  cases  it 
is  diffuse  and  of  an  intense  scarlet  or  almost  purple  color.  Again,  it 
shows  a  marked  tendency  to  stain  the  tissues,  and  even  minute  haemor- 
rhages may  occur  with  the  formation  of  petechias.  In  these  cases  the 
eruption  is  often  extremely  pronounced  over  the  dorsum  of  the  hands 
and  feet,  where  it  may  acquire  a  peculiar,  intensely  livid  hue.  In  cases 
of  this  type  in  which  the  rash  is  of  a  transient  character,  and  associated 
with  the  intense  local  pharyngeal  symptoms,  the  diagnosis  is  often 
extremely  difficult. 

With  the  appearance  of  the  eruption  the  temperature  rises  beyond 
the  initial  mark,  the  pulse  becomes  more  rapid,  and  all  the  local  symp- 
toms— headache,  thirst,  and  sore  throat — are  much  aggravated,  while 
the  constitutional  depression  is  extreme.  The  mucous  membrane  of 
the  pharynx  is  acutely  inflamed;  the  tonsils  are  greatly  swollen,  and 
after  the  second  day,  in  addition  to  the  irregular  covering  of  grayish 
exudate,  may  show,  here  and  there,  distinct  necrotic  areas:  an  appear- 
ance readily  confused  with  true  diphtheria. 

The  difficulty  in  swallowing  increases,  and  even  on  the  second  day 
it  may  be  that  only  liquids  can  be  taken,  while  not  infrequently  the 
gastric  disturbance  is  so  severe  from  the  onset  that  nothing  can  be 


!>'.'  THE   ACUTE    EXANTHEMATA. 

retained  in  the  stomach.  Not  uncommonly  the  gastric  irritability  per- 
sists, making  the  problem  of  feeding  throughout  the  course  of  the  dis- 
ease a  difficult  one,  while  the  persistent  vomiting  adds  to  the  exhaus- 
tion. The  secretion  of  urine  is  diminished,  albumin  is  present,  and, 
microscopically,  hyaline  and  epithelial  casts  and  frequently  blood  may 
be  found.  There  is  great  restlessness,  delirium  may  supervene,  and 
the  prostration  is  profound.  As  the  disease  progresses  the  temperature 
continues  elevated,  assuming  an  irregular  type  and  ranging  between 
103°  and  105°  F.  (39.4°  and  40.5°  C.).  The  local  pharyngeal  symp- 
toms increase  in  severity.  The  tongue  is  thickly  coated,  swollen,  the 
papillae  prominent  and  the  tip  and  edges  reddened,  and  it  early  assumes 
the  characteristic  appearance.  The  inflammation  and  necrosis  of  the 
tonsils  advance,  and  are  followed  by  ulceration,  with  extensive  slough- 
ing, the  discharge  of  broken-down  exudate  and  tissue,  causing,  as  a 
rule,  the  most  distressing  cough,  associated  with  profuse  expectora- 
tion. The  neighboring  chains  of  lymphatic  glands  are  acutely  swollen, 
easily  palpable,  and  tender.  In  some  cases  an  excessive  infiltration  of 
the  cellular  tissue  of  the  neck  takes  place,  which  is  occasionally  to 
marked  that  the  overstretched  tissue  encircles  the  neck  as  a  collar. 

The  local  pharyngeal  inflammation  may  even  extend  to  the  poste- 
rior nasopharynx,  with  the  development  of  a  muco-purulent  discharge 
from  the  nares,  which  is  intensely  irritating  to  the  skin,  giving  rise  to 
the  formation  of  rhagades  about  the  nostrils  and  lips;  or  it  may  extend 
along  the  Eustachian  tubes,  involving  one  or  both  ears,  with  subse- 
quent rupture  of  the  membrana  tympani  and  discharge  of  the  puru- 
lent accumulation. 

The  secretion  of  urine  diminishes.  At  times  it  is  almost  sup- 
pressed, and  not  infrequently,  by  the  fourth  or  fifth  day,  slight  or 
pronounced  ursemic  twitchings  are  seen.  The  pulse  is  weak  and  rapid 
(130  to  150  to  the  minute)  and  frequently  irregular:  always  a  grave 
sign  in  scarlatina. 

In  this  type  of  the  disease  the  heart-sounds  may  early  lose  their 
normal  tone  and  character,  the  first  sound  particularly  being  weak, 
while  not  uncommonly,  by  the  fourth  to  the  sixth  day,  the  two  sounds 
may  be  indistinguishable.  Less  commonly,  transitory  murmurs  are 
heard,  and  more  rarely,  actual  dilatation  of  the  heart  may  be  made 
out. 

Not  Infrequently  by  the  sixth  to  the  seventh  day — after  the  symp- 
toms have  persisted  as  above,  often  with  pronounced  cerebral  disturb- 
ance, as  evidenced  by  great  restlessness  with  active  delirium,  or  again 


SCARLATINA.  163 

by  extreme  apathy  and  stupor,  the  clinical  picture  being  that  of  a 
grave  septicaemia — there  is  a  change  for  the  better,  and  the  turning- 
point  in  the  attack  is  reached.  In  many  cases  of  this  type  which  re- 
cover the  improvement  in  the  symptoms  is  not  seen,  however,  until 
late  in  the  second  week.  The  temperature  falls;  the  pulse  becomes 
less  rapid,  regular,  and  of  better  quality;  and  the  cerebral  symptoms 
gradually  improve:  though  not  uncommonly,  following  a  period  of 
active  cerebral  disturbance,  associated  with  great  prostration,  mild  re- 
current delirium,  coming  on  toward  evening,  may  persist  for  three  or 
four  days.  The  local  ulcerative  process  in  the  pharynx  is  checked  and 
improves  slowly.  The  inflammation  of  the  lymphatic  glands  subsides. 
The  secretion  of  urine  becomes  more  abundant;  and  early  in  the  third 
week  desquamation  begins,  and  convalescence — though  in  such  cases 
prolonged  beyond  the  so-called  normal  period — is  gradually  estab- 
lished. In  these  cases  desquamation  frequently  advances  slowly,  and 
may  be  still  incomplete  by  the  twelfth  week,  rarely  later,  being  present 
at  this  time  between  the  fingers  and  toes. 

In  cases  which  prove  fatal,  either  directly  through  the  overwhelm- 
ing toxemia,  or  indirectly,  from  the  development  of  some  intcrcurrent 
complication,  which,  if  present,  may  be  detected,  as  a  rule,  by  the 
physical  signs,  or  subjective  symptoms,  the  course  of  the  attack  is  fre- 
quently more  abrupt.  The  temperature  early  becomes  more  irregularly 
septic  in  type,  with  a  daily  variation  of  three  or  more  degrees,  ranging 
between  103°  and  106°  F.  (39.4°  and  41.1°  C.)  or  even  higher;  the 
pulse  grows  weaker,  more  rapid,  and  irregular;  the  respirations  may 
be  quick  and  short,  or  slow  and  labored;  the  local  ulceration  in  the 
pharynx  is  extreme,  and  the  constitutional  depression  profound.  The 
condition  of  the  patient  is  one  of  marked  stupor  and  apathy,  or  less 
commonly  there  is  great  restlessness,  which  gives  way  to  active  de- 
lirium, followed  later  by  coma;  while  frequently  toward  the  close  of 
the  attack  a  profuse  diarrhoea  sets  in,  together  with  a  critical  diapho- 
resis, and  the  patient  succumbs  to  the  severity  of  the  infection,  late  in 
the  first  or  early  in  the  second  week  of  the  attack. 

TOXIC  SCAELET  FEVEE. 
(Scarlatina  maligna;    la  scarlatine  foudroyante.) 

This  type  of  the  disease,  fortunately  rare  (occurring  only  in  about 
2  per  cent,  of  all  cases  of  scarlatina),  is  characterized  by  the  great 
abruptness  of  its  onset,  associated  from  the  first  with  an  overwhelming 


184  THE   ACUTE    EXANTHEMATA. 

intoxication  by  the  scarlatinal  poison,  excessively  high  temperature, 
pronounced  cerebral  disturbance,  a  grave  tendency  to  the  occurrence 
of  haemorrhages  into  the  skin  and  from  the  mucous  surfaces,  and  pro- 
found prostration,  and  usually  proves  fatal  within  the  first  three  days. 

Under  this  head  are  included  the  ATAXIC,  ADYNAMIC,  and  H.EM- 
ORRHAGIC  FORMS.  The  onset  is  abrupt  and  explosive;  a  child,  to  all 
appearances  well,  is  seized  with  a  sudden  and  violent  attack  of  vomit- 
ing, associated  occasionally  with  an  abrupt  and  profuse  diarrhoea,  or 
again  severe  and  prolonged  convulsions  are  the  first  indication  of  the 
infection.  The  temperature  rises  rapidly,  reaching  105°  to  107°  F. 
(40.5°  to  41.6°  C.)  within  the  first  few  hours  and  frequently  higher, 
temperatures  of  110°  F.  (43.3°  C.)  and  even  111°  F.  (43.8°  C.)  having 
been  recorded.  The  pulse  becomes  very  rapid  (140  to  160  to  the  min- 
ute), weak,  irregular,  and  intermittent.  The  cheeks  and  lips  are 
blanched,  and  may  early  show  slight  cyanosis.  The  urine  is  scanty, 
high  colored,  albuminous,  or  may  be  completely  suppressed. 

Following  the  initial  symptoms,  the  condition  of  the  child  rapidly 
becomes  alarming.  The  cerebral  disturbance  is  extreme,  the  headache 
is  intense,  and  the  convulsions  give  way  to  active  delirium.  There  is 
frequently  marked  dyspnoea,  the  respiratory  rhythm  being  short  and 
quick,  due  usually  not  to  any  change  in  the  lungs  at  this  time,  but 
probably  to  irritation  of  the  respiratory  centres,  as  emphasized  by 
Ausset.301  » 

The  local  pharyngeal  inflammation  may  be  severe,  though  fre- 
quently masked  by  the  intensity  of  the  general  symptoms;  again,  it 
is  wholly  wanting,  the  course  of  the  disease  progressing  with  such 
rapidity  as  to  prove  fatal  before  pronounced  development  of  the  local 
angina.  The  eruption  appears  early,  is  diffuse  and  general  in  distribu- 
tion, or  irregular  and  of  a  brilliant  or  dusky  color,  patchy  and  fleeting 
in  character,  while  at  times  it  is  so  evanescent  as  to  seem  wholly  want- 
ing. Quickly  following  the  early  development  of  the  attack  coma  de- 
velops and  the  child  sinks  rapidly,  succumbing — not  infrequently 
within  forty-eight  hours — to  the  intense  toxaemia. 

The  so-called  ataxic  and  adynamic  forms  are  characterized  by 
early  and  profound  constitutional  depression, — the  result  of  the  direct 
action  of  the  specific  toxin  upon  the  nerve-centres, — the  symptoms  rap- 
idly assuming  a  grave  typhoidal  type. 


101  Ausset  (E.):  "Legons  Cliniques  sur  les  Maladies  des  Enfants"  (Paris,  1895),  p. 
251. 


SCARLATINA.  J85 

The  temperature  rises  abruptly,  the  pulse  becomes  weak,  rapid, 
irregular,  and  easily  compressible;  and  the  respirations  rapid  and 
shallow.  The  mouth  soon  becomes  parched,  the  tongue  dry,  and  the 
lips  cracked.  The  bowels  are  loose,  the  movements  frequently  being 
passed  involuntarily;  and  the  secretion  of  urine  is  greatly  diminished 
or  completely  suppressed. 

A  low  delirium  followed  by  coma  rapidly  ensues,  and  the  case  often 
ends  fatally  before  the  appearance  of  the  exanthem  or  marked  develop- 
ment of  the  angina. 

In  the  hcemorrhagic  forms  characterized  by  the  occurrence  of  hasm- 
orrhages  from  the  mucous  surfaces,  and  into  the  skin,  the  eruption  is, 
for  the  greater  part,  but  imperfectly  developed.  The  exanthem  early 
acquires  a  dark  purplish  hue,  and  is  not  readily  obliterated  by  pressure, 
showing  a  manked  tendency  to  stain  the  tissues.  Within  the  first  forty- 
eight  hours  small  petechiae,  varying  in  size  from  a  pin-head  to  a  lentil, 
with  a  sharply  defined  margin,  appear  scattered  irregularly  over  the 
body.  The  lower  extremities,  or  the  trunk  alone,  may  be  involved, 
while  the  arms  and  neck  remain  free.  At  the  same  time  petechiag  may 
be  seen  upon  the  mucous  membranes  of  the  gums,  or  epistaxis  may 
occur. 

In  the  grave  forms  of  this  type  of  the  disease  the  tendency  to 
haemorrhages  from  the  mucous  surfaces  is  greatly  increased.  Early  and 
persistent  vomiting  not  uncommonly  suggests  the  nature  of  the  attack, 
the  vomitus  being  frequently  at  this  time  dark  in  color. 

The  petechise  already  described  appear,  and  may  coalesce  over  a 
limited  area,  or  fresh  deep  purple  ecchymoses,  of  a  large  size,  develop 
on  various  parts  of  the  body.  Blood  oozes  from  the  gums,  the  sputum 
being  even  tinged  with  it,  while  the  epistaxis  may  be  severe.  Blood 
is  discharged  from  the  bowels,  or  the  stools  may  be  tarry  in  color. 
Hemorrhages  occur  from  the  genito-urinary  tract,  or  the  urine  shows 
the  presence  of  blood  in  great  excess.  Earely  the  pleuraa  or  pericardium 
may  be  the  seat  of  extensive  haemorrhagic  exudation. 

The  skin  which  may  show  elsewhere  a  faint  or  deeper  scarlet 
blush,  becomes  flabby  and  wrinkled,  while  in  rare  instances  the  face 
may  be  actually  bloated. 

The  pulse  is  weak,  rapid,  and  easily  compressed;  the  respirations 
hurried,  and  the  patient  usually  sinks  quickly  into  a  state  of  profound 
collapse. 

Death  is,  in  these  cases,  the  almost  invariable  result,  occurring  not 
infrequently  within  ten  or  twenty  hours  after  the  onset.  Recovery  is 


186  THE    ACUTE    EXANTHEMATA. 

possible,  according  to  Thomas,  in  the  milder  types  of  this  form  of  the 
disease. 

As  a  rule,  young  children  between  one  and  two  years  of  age,  with 
but  poorly  developed  constitutions  and  greatly  lowered  vitality,  are 
the  subjects  of  this  form  of  scarlatina,  though  older  children  may  be 
attacked,  and  even  adults  are  not  wholly  exempt. 

IRREGULAR  FORMS  OF  SCARLET  FEVER.    (Scarlatina 
Mvdificata.) 

Any  classification  of  the  many  clinical  types  of  scarlatina  into 
one  of  the  above  distinct  groupings  must  remain  of  purely  theoretical 
value.  So  great  is  the  variation  in  each  case  that  not  infrequently  the 
three  types  of  the  disease  may  run  together,  making  a  sharp  differentia- 
tion impossible.  Considering  the  simple  type — scarlatina  simplex — as 
the  normal,  all  other  forms  are  essentially  irregular,  and  are  so  classified 
by  many  observers. 

Other  well-recognized  irregular  or  anomalous  forms  may  be  di- 
vided into  those  in  which:  (a)  the  eruption  is  almost,  if  not  wholly, 
absent;  (&)  those  in  which  the  chief  marked  variation  is  in  the  un- 
usual or  abnormal  character  of  the  eruption;  (c)  those  forms  charac- 
terized by  irregularities  in,  or  complete  absence  of,  any  marked  rise 
in  the  temperature;  and  (d)  those  cases  in  which  the  angina  is  of 
unusually  mild  degree. 

(A)  SCARLATINA  SINE  EXANTHEMATA. — Mayr  states  (loc.  cit.,  p. 
195)  that  this  expression  is  only  justified  in  those  cases  in  which,  in  a 
given  group  or  family,  otherwise  typical  attacks  of  scarlatina  occur, 
associated  with  angina  and  fever  without  eruption,  and  consequent  des- 
quamation.  Thomas  (loc.  cit.,  p.  251)  in  describing  the  "rudimentary" 
and  "mild"  forms  says  that  every  throat  affection  during  a  scarlet- 
fever  epidemic  should  be  regarded  with  suspicion,  and,  further,  in  the 
absence  of  satisfactory  etiological  evidence,  the  scarlatinal  nature  of 
the  attack  may  be  proved  by  the  subsequent  occurrence  of  the  charac- 
teristic desquamation,  even  when  there  has  been  no  previous  trace  of 
an  eruption,  or  by  the  appearance  of  a  moderate  amount  of  dropsy  with 
albuminuria.  Henoch302  holds  that  many  cases  of  scarlatina  do  un- 
doubtedly occur  in  which  the  eruption,  though  rarely  completely  ab- 
sent, has  been  overlooked,  being  either  so  scanty  or  of  such  a  super- 

301  Henoch  (Ed.):  "Chartte  Annalen,"  III  Jahrgang,  1876,  p.  553.  "Mittheilungs 
ueber  das  Scharlachfleber,"  and  Vorlesung.  (loc.  cit.),  p.  861. 


SCARLATINA.  187 

ficial  erythematous  type  as  to  be  thought  of  no  especial  significance; 
"and  that  only  a  subsequent  nephritis  or  a  true  desquamation  renders 
the  diagnosis  in  these  cases  positive."  That  instances  do  occur  in 
which  the  eruption  is  wholly  absent  is  the  opinion  of  many  observers, 
and  that  there  are  many  cases  in  which  the  rash  is  of  such  an  evanes- 
cent character  that  it  entirely  escapes  notice  must  be  admitted.  The 
difficulty  of  diagnosis  in  these  instances  may  be  extreme,  the  occur- 
rence of  a  characteristic  desquamation  being  by  no  means  an  abso- 
lutely infallible  sign  of  the  previous  existence  of  scarlet  fever,  while 
the  nephritis  may  be  absent. 

(B)  SCARLATINA  L.EVIS. — This  term  applies  to  the  form  of  erup- 
tion seen  in  the  ordinary  mild  or  simple  type  of  the  disease. 

SCARLATINA  L^YIGATA. — Canstatt  (see  Mayr,  loc,  cit.,  p.  195)  has 
given  this  name  to  a  variety  of  the  exanthem  of  a  more  intense  char- 
acter than  the  simple  type.  In  these  cases  the  rash  acquires  a  peculiar 
shining,  glossy  appearance,  and  the  mucous  membranes  are  markedly 
involved. 

SCARLATINA  MILIARIS  (Scharlachfriessel). — In  this  type  of  the 
eruption  small  vesicles  containing  a  clear,  white  fluid  of  alkaline  re- 
action develop,  being  seen  chiefly  on  the  trunk,  though  occasionally 
also  upon  the  extremities  and  scattered  over  the  body.  According  to 
Eichhorst  (loc.  cit.,  iv,  p.  256),  the  occurrence  of  this  form  of  the  ex- 
anthem  is  especially  favored  by  profuse  sweating,  though  it  appears 
independently  of  it,  as  a  sequel  to  an  extensive  exudation  between  the 
rete  Malpighii  and  the  epidermis.  In  some  instances  the  single  vesicles 
become  larger,  simulating  herpes,  or  they  may  even  acquire  varicella- 
like  and  pemphigoid  forms. 

SCARLATINA  PAPULOSA.  —  In  cases  thus  named  small,  slightly- 
elevated  papules  of  a  dark-red  color  develop  at  the  site  of  the  hair 
follicles  as  a  result  of  an  unusual  exudation  into  the  mouths  of  the 
hair  sacs.  Occasionally  they  are  more  readily  detected  by  the  finger 
than  by  the  eye,  and  in  some  instances  (Mayr,  loc.  cit.,  p.  196)  are 
observed  twelve  to  eighteen  hours  before  the  ordinary  scarlatinal  rash 
appears. 

SCARLATINA  H^MORRHAGICA  (sen  Septica). — This  type  of  the 
eruption,  as  has  been  described  under  the  toxic  forms  of  scarlatina,  is 
characterized  by  the  presence  of  hemorrhages  from  the  mucous  sur- 
faces and  into  the  skin;  and  is,  of  course,  to  be  differentiated  from 
those  in  which  small  isolated  hemorrhages  occur  in  the  skin,  but  are 
of  no  especial  significance. 


188  THE   ACUTE    EXANTHEMATA. 

SCARLATINA  VARIEGATA. — This  form  is  marked  by  an  extremely 
irregular  distribution  of  the  eruption  frequently  associated  with  the 
development  of  well  defined  macular  areas  of  an  intense-red  color 
situated  at  the  sites  of  the  hair  follicles,  and  in  many  instances  simu- 
lating the  exanthem  of  measles.  Between  these  macular  spots  of  bright 
red  the  skin  is  generally  covered  by  a  uniform,  but  pale,  rash.  Barely 
these  macules  coalesce,  while  more  commonly  they  undergo  no  altera- 
tion. Henoch  (Vorles,  loc.  cit.,  p.  650)  is  of  the  opinion  that  the  ap- 
pearance of  this  type  of  the  eruption  is  usually  indicative  of  an  un- 
favorable course  of  the  disease,  though  this  is  not  always  the  case. 

In  any  large  number  of  cases,  in  addition  to  these  well-recognized 
irregular  forms,  a  great  variation  is  seen  in  the  duration  of  the  erup- 
tion, which  may  be  unusually  prolonged,  lasting,  in  some  instances, 
even  from  one  to  two  weeks.  Again,  a  fresh  outbreak  of  the  eruption, 
following  an  almost  complete  desquamation  of  the  skin,  may  occur 
though  probably  this  secondary  rash  is,  in  the  majority  of  instances, 
more  of  the  nature  of  an  erythema  than  a  true  scarlatinal  eruption.303 

(C)  SCARLATINA  SINE  FEBRE. — Among  the  extremely  mild  cases 
of  scarlatina  instances  are  frequently  seen  in  which,  after  a  slight  initial 
rise,  the  disease  progresses  without  any  subsequent  elevation  of  tem- 
perature beyond  98.5°  to  99°  F.  (36.5°  to  38°  C.),  while  every  other 
symptom  of  the  disease  is  present,  though  in  a  mild  degree.  That 
cases  occur  which  would  admit  of  the  literal  interpretation  of  this 
definition — i.e.,  without  any  fever — is  extremely  doubtful,  and  Wun- 
derlich304  has  pointed  out  the  difficulty  of  determining  this  point,  due 
to  the  fact  that  these  extremely  mild  cases  are  rarely  seen  at  the  outset. 
In  McCollom's  series  there  were  thirty-seven  cases  with  a  temperature 
of  but  99°  F.  (38°  C.),  and  many  such  cases  are  reported  in  literature. 
Other  well-marked  irregularities  in  the  course  of  the  temperature  are 
seen  but  rarely,  there  being  in  some  few  instances  (4  cases  in  175, 
Henoch)  a  pronounced  daily  intermission,  the  temperature  falling  to 
normal  in  the  morning  associated  with  a  high  evening  rise.  Less  com- 
monly cases  are  seen  in  which,  after  the  temperature  has  remained  for 
a  few  days  between  100°  and  101.5°  F.  (39°  and  40.5°  C.),  it  falls 
abruptly  to  normal,  and  the  subsequent  course  of  the  disease  continues 
without  any  further  elevation.  Under  the  head  of  fever  of  an  "In- 


103  Kaposi  (M.):  "Path.  u.  Therapie  der  Hautkrankheiten"  (Berlin  und  Wien    1899), 
p.  236. 

**  Wunderlich  (C.  A.):  "Das  Verhalten  der  Eigenwarme  in  Krankheiten"  (Leip- 
zig, 1870),  p.  330. 


PLATE  XXXIII. 


PLATE  XXXIIT. 


Scarlatina  and   Varicella   Co-existing. 


SCARLATINA.  189 

verted  Type"  Henoch  ("Char.  Annal.,"  loc.  cit.,  p.  513)  has  further 
described  the  occurrence  of  a  temperature  curve  quite  the  reverse  of 
the  normal,  in  which  the  temperature  was  higher  in  the  morning  than 
in  the  evening. 

(D)  SCARLATINA  SINE  ANGINA. — This  term  has  been  applied  to 
those  cases  of  unusually  mild  degree  in  which  the  subjective  throat 
symptoms  are  very  slight,  or  so  insignificant  as  to  appear  wholly  want- 
ing. In  these  cases  there  is  always  some  congestion  of  the  throat,  and 
usually  a  faint  enanthem  can  be  made  out  early  in  the  course  of  the  dis- 
ease. The  tonsils  are  not  enlarged,  but  there  is  an  almost  constant, 
even  though  slight,  enlargement  of  the  papillae  at  the  tip  and  edges 
of  the  tongue:  a  point  frequently  of  no  little  diagnostic  value. 

OCCURRENCE  or  SCARLATINA  WITH  OTHER  ACUTE  EXANTHEMATA. 
— It  has  been  well  established  by  a  large  number  of  carefully  reported 
cases  that  the  existence  of  scarlet  fever  in  an  individual  does  not  pre- 
vent a  secondary  infection  with  any  of  the  other  acute  exanthemata, 
— such  as  measles,  chicken-pox  (see  Plate  XXXIII),  or  small-pox 
(q.  v.,  p.  81), — although  it  must  be  acknowledged  that  this  is  exceed- 
ingly infrequent.  When  such  coincidences  do  occur,  however,  it  has 
been  observed  that  the  secondary  infection  takes  place  late  in  the  course 
of  the  first,  and  most  frequently  after  all  traces  of  the  primary  exan- 
them  have  disappeared,  and  the  eruption  of  the  secondary  disease  pre- 
dominates. It  is  claimed  by  some,  that  occasionally  the  eruption  of 
measles,  chicken-pox,  or  even  small-pox  may  be  present  together  with 
the  scarlatinal  rash,  so  that  three  distinct  exanthemata  may  occur 
simultaneously.  This,  however,  we  have  never  seen.  When  the  pri- 
mary affection  has  entirely  subsided  the  appearance  of  another  acute 
exanthem  does  not,  as  a  rule,  greatly  modify  the  one  or  the  other. 
Murchison  (Lancet,  loc.  cit.},  however,  has  well  emphasized  the  fact 
that,  when  two  exanthemata  co-exist,  one  is  usually  mild  and  more  or 
less  ill  defined.  This  is  liable  to  lead  to  great  confusion  in  diagnosis, 
and,  while  the  possibility  of  the  co-existence  of  two  distinct  exan- 
themata in  the  same  individual  should  not  be  lost  sight  of,  the  fre- 
quency of  prodromal  scarlatiniform  rashes  in  variola,  and  to  a  less 
extent  in  rubeola,  must  constantly  be  borne  in  mind. 

The  existence  of  other  cutaneous  affections  during  the  period  of 
the  scarlatinal  eruption  is  not  uncommon,  and  may  be  evidenced  by 
simple  or  toxic  erythemas,  by  the  presence  of  an  urticarial  rash,  or  by 
single  scattered  vesicles,  pustules,  or  petechiae,  which  are  dependent, 
except  in  the  case  of  the  toxic  erythemas,  upon  a  local  alteration  in 


190  THE   ACUTE    EXANTHEMATA. 

the  tension  of  the  blood-vessels  with  unusual  permeability  and  exuda- 
tion from  them.  In  the  ha?morrhagic  or  septic  type  the  condition  is 
one  of  true  purpura  co-existing  with  the  scarlatinal  rash. 

The  chronic  diseases  of  the  skin,  such  as  eczema  and  psoriasis, 
usually  subside  in  intensity  during  the  period  of  eruption  in  scarla- 
tina, increasing  again  in  activity  with  the  establishment  of  convales- 
cence. Even  in  scabies  we  have  often  remarked  that  the  itching  seems 
to  be  less  severe,  if  not  wholly  absent,  during  an  attack  of  scarlatina. 
It  does  not,  however,  impair  the  vitality  of  the  Acarus. 


COMPLICATIONS. 

The  Throat. — The  early  and  marked  involvement  of  the  pharynx 
and  fauces  in  scarlatina,  while  essentially  a  symptom  of  the  infection 
as  seen  in  the  mildest  type  (angina  scarlatinosa  simplex),  may  consti-, 
tute  one  of  the  gravest  complications  of  the  disease,  leading  to  severe 
ulcerations  with  far-reaching  and  disastrous  results.  Although  it  is 
highly  probable  that,  under  certain  circumstances,  the  scarlatinal  virus 
alone  is  capable  of  producing  inflammation  of  the  pharyngeal  mucous 
membrane  associated  with  more  or  less  necrosis,  yet  in  all  those  cases 
characterized  by  extensive  destruction  of  the  tissues,  or  by  the  forma- 
tion of  a  false  membrane,  as  well  as  in  many  of  the  less  severe  types, 
the  presence  of  known  pathogenic  micro-organisms  has  long  since  been 
well  recognized. 

In  this  connection  von  Jiirgensen  (loc.  cit.,  p.  130)  holds  that,  so 
long  as  we  know  nothing  of  the  specific  cause  of  scarlatina  it  is  im- 
possible to  determine  in  how  far  the  scarlatinal  virus,  unassociated  with 
other  pathogenic  microbes,  is  responsible  for  the  severer  forms  of  ne- 
crotic  inflammation.  At  the  same  time  he  expresses  his  belief  that  the 
scarlatinal  poison  is  in  itself  capable  of  giving  rise  to  such  inflamma- 
tory reaction.  Moreover,  Henoch  (loc.  cit.,  For.,  pp.  661  et  seq.)  lays 
great  stress  on  the  tendency  to  such  inflammations  with  necrosis — 
"necrotisirenden  Entzundungen" — as  a  result  of  the  specific  scarlatinal 
infection. 

The  great  confusion  which  existed  for  many  years  with  reference 
to  the  etiology  of  the  pseudomembranous  anginas  in  scarlet  fever  has 
been  done  away  with.  The  researches  of  many  investigators305  in 
Europe,  as  well  as  in  this  country,  have  definitely  established  the  fact 

""Loeffler:  Deut.  klin.  Woch.,  Nos.  39  and  40,  1890.  Bourges  and  Wurtz:  Prog. 
M£d.,  May  10,  1890.  Bourges:  Gaz.  Hebd.,  No.  13,  1891,  et  al. 


SCARLATINA.  191 

that  the  Klebs-Loeffler  bacillus  is  absent  in  a  great  majority  of  cases 
in  the  early  scarlatinal  angina,  occurring  very  rarely  in  combination 
with  the  streptococcus  pyogenes,  which  is  almost  constantly  present. 
Lemoine,306  in  a  bacteriological  study  of  117  cases  of  scarlatinal  angina, 
found  the  streptococcus  pyogenes  alone  in  93,  while  the  Klebs-Loettler 
bacillus  was  found,  in  addition,  in  5,  and  the  bacillus  coli  communis  in 
9  cases.  The  staphylococcus  pyogenes  aureus  is  found  occasionally, 
and  more  rarely  other  pathogenic  micro-organisms,  together  with  the 
streptococcus.  It  has  thus  been  definitely  proved  that  the  streptococcus 
is  the  main  etiological  elemen.t  in  these  cases. 

Under  circumstances  favoring  the  exposure  of  the  individual  to 
the  contagion  of  diphtheria,  the  presence  of  Klebs-Loeffler  bacilli  in 
the  pharynx  at  this  time  might  naturally  be  the  result,  and  the  local 
process  should  then  be  regarded  as  essentially  a  true  diphtheria  com- 
plicating early  scarlatina,  which  is,  however,  a  rare  occurrence. 

Aggravated  angina  scarlatitwsa  simplex — while  not,  in  reality,  a 
true  complication — may  be  justly  considered  as  such,  in  those  instances 
in  which  it  persists  beyond  the  normal,  causing  a  prolongation  of  the 
febrile  period,  and  an  aggravated  local  inflammation,  without  other 
serious  manifestation. 

Angina  Pseudomembranosa  (of  Streptococcic  Origin). — Cases  char- 
acterized by  the  development  of  a  false  membrane  upon  the  tonsils 
and  in  the  pharynx  are  seen  in  the  severe  or  septic  type  of  the  disease, 
in  which  the  local  pharyngeal  symptoms  early  acquire  unusual  promi- 
nence. 

By  the  second  day  the  mucous  membrane  of  the  pharynx  is  in- 
tensely reddened  and  congested,  the  tonsils,  which  are  much  inflamed 
and  swollen,  show  here  and  there  scattered,  irregular,  patches  of  gray 
or  grayish-white  exudate,  completely  occluding  the  tonsillar  crypts  over 
a  more  or  less  limited  surface.  The  neighboring  lymphatic  glands  are 
enlarged,  readily  palpable,  and  tender.  One  or  both  tonsils  may  be  in- 
volved, and,  while  it  is  commoner  to  find  both  sides  affected,  the  process 
may  be  more  pronounced  on  one  side.  In  many  cases  the  local  process 
is  limited  to  these  irregular  patches  of  exudate,  which  remain  sharply 
defined  on  the  tonsils;  or,  again,  small  foci  may  be  seen  upon  the  soft 
palate,  causing,  in  either  case,  but  slight  destruction  of  tissue.  In  these 
less  extensive  cases  after  five  or  six  days  resolution  begins,  the  patches 


80(1  Lemoine  (G.  H.):  "Rflle  du  Streptococque  dans  la  Scarlatine  et  ses  Complica- 
tions." Bull,  et  Mem.  de  la  Soc.  des  H6p.  de  Paris,  1895;  ibid.,  1896,  iii,  S.  xiii,  303-319. 
See  Soc.  Proceed.  Gaz.  des  H6p.,  December  24,  1895,  p.  1449. 


192  THE   ACUTE    EXANTHEMATA. 

of  exudate  become  gradually  smaller,  while  the  local  symptoms  slowly 
improve. 

In  many  instances,  however,  the  pharyngeal  inflammation,  asso- 
ciated with  a  severe  scarlatinal  infection,  from  the  first  shows  an  ex- 
treme grade  of  intensity.  By  the  second  or  third  day  the  tonsils  are 
markedly  inflamed,  greatly  swollen,  and  covered  by  an  irregular  gray 
or  grayish-white  membrane,  which  spreads  rapidly,  covering  the  poste- 
rior pharyngeal  wall,  the  hard  palate,  and  the  mucous  membrane  of  the 
posterior  surface  of  the  cheeks.  This  may  even  spread  to  the  poste- 
rior nares  and  Eustachian  tube  with  resulting  extension  of  the  inflam- 
matory process  to  the  middle  ear.  The  salivary  and  buccal  secretions 
are  increased,  are  of  a  foetid  odor,  and  may  be  blood-tinged,  and  the 
breath  early  acquires  a  peculiarly  disagreeable  smell.  The  neighboring 
chains  of  lymphatics,  particularly  the  submaxillary  glands,  are  greatly 
enlarged,  readily  palpable,  and  acutely  sensitive  to  pressure.  With  the 
involvement  of  the  posterior  nares  there  develops  a  severe  coryza,  with 
the  discharge  of  a  thin,  acrid,  sero-purulent,  and  often  blood-tinged 
fluid  from  the  nostrils,  which  is  extremely  irritating  to  the  sensitive 
skin  about  the  nostrils  and  lips,  and  leads  readily  to  the  formation  of 
slight  or  extensive  fissures  and  rhagades. 

With  the  extension  of  the  membrane,  which  varies  at  this  time 
from  gray  or  grayish-green  to  an  almost  black  color,  there  follows  a 
severe  necrosis,  ulceration,  and  sloughing  of  the  tissues,  while  the  irri- 
tation arising  from  the  discharge  of  broken-down  material  and  ex- 
cessive secretion  gives  rise  to  a  most  distressing  cough.  The  nostrils 
may  be  occluded,  and  the  mouth  held  open  in  the  attempt  to  breathe. 
The  infiltration  and  swelling  of  the  lymphatic  glands  may  be  extreme, 
and  in  rare  instances  an  excessive  infiltration  of  the  cellular  tissue  of 
the  neck  occurs,  which  becomes  hard  and  indurated,  and  exceptionally 
renders  the  head  quite  immovable. 

The  temperature  is  elevated,  the  pulse  rapid  and  weak,  and  the 
constitutional  depression  extreme.  The  clinical  picture  is  one  of  pro- 
found septicaemia,  and  when  seen  early,  before  the  appearance  of  the 
eruption,— as  is  often  the  case  in  this  type  of  the  disease,— the  diffi- 
culty of  diagnosis  may  be  great. 

Angina  Gangranosa.  —  In  a  small  percentage  of  cases  the  local 
process  in  the  pharynx  early  assumes  a  gangrenous  type,  or  the  pseudo- 
membranous  form  quickly  becomes  so,  being  followed  by  deep  and  ex- 
tensive ulceration,  affecting  not  only  the  tonsils,  but  the  pillars  of  the 
pharynx,  the  uvula,  and — in  rare  instances — the  deeper  cellular  tissue 


SCARLATINA.  193 

of  the  neck.  This  is  seen  only  in  the  gravest  type  of  scarlatina.  In 
these  cases  the  tonsils  are  greatly  swollen  and  covered  by  an  extensive 
dark  grayish-black  exudate,  which  spreads  over  the  neighboring  struct- 
ures with  unusual  rapidity.  The  necrotic  tissue  may  be  removed,  leav- 
ing deep  ulcerative  and  sloughing  areas,  which  bleed  readily.  Large 
masses  of  the  tonsils  may  slough  off,  perforation  of  the  soft  palate  may 
even  take  place,  and,  in  rare  instances,  haemorrhages  may  occur  from 
the  large  vessels  of  the  neck.  The  breath  is  foul,  the  discharges  from 
the  mouth  and  nostrils  are  excessive,  and  the  glandular  swelling  very 
marked.  The  constitutional  symptoms  are,  from  the  onset,  those  of  a 
profound  toxaemia,  with  great  prostration.  There  is  but  a  slight  tend- 
ency to  repair;  hence  these  cases  are  commonly  fatal. 

Angina  Scarlatinosa  Membranosa  (of  True  Diphtheritic  Origin). 
— Diphtherial  complication  occurs,  as  a  rule,  later  in  the  course  of  the 
disease,  and  after  complete  subsidence  of  all  the  primary  pharyngeal 
symptoms.  Its  course  is  almost  identical  with  that  seen  in  the  early 
pseudomembranous  form,  and  is  due  to  a  secondary  infection  with  the 
Klebs-Loeffler  bacillus.  It  is,  therefore,  essentially  a  true  diphtheria 
complicating  the  scarlatinal  process.  Anatomically,  it  may  be  impos- 
sible to  distinguish  the  resulting  lesions  in  these  cases  from  those  seen 
as  the  result  of  the  streptococcus  pyogenes.  Clinically,  however,  it 
may  be  distinguished  from  the  early  angina  of  streptococcic  origin  by 
the  much  greater  tendency  to  invade  the  larynx  and  upper  air-passages, 
and  by  the  far  more  frequent  resulting  diphtheritic  paralysis.  It  is  a 
well  established  fact  that  paralyses  which  can  be  called  "diphtheritic" 
do  not  follow  the  early  scarlatinal  anginas  associated  with  necrosis  of 
the  pharynx,  except  in  the  rarest  instances.  Henoch  (For.,  loc.  cit.,  p. 
665)  has  never  observed  oculomotor  or  palatal  paralyses  following  a 
scarlatinal  angina,  except  in  those  cases  complicated  by  a  true  diph- 
theria. 

Otitis. — Inflammation  of  the  middle  ear  as  a  result  of  the  direct 
extension  of  the  local  pharyngeal  process  along  the  Eustachian  tube 
constitutes,  perhaps,  the  commonest  complication  of  scarlet  fever.  In 
a  few  exceptional  cases  the  local  inflammation  of  the  skin  may  extend 
upward  on  the  side  of  the  head,  involving  the  external  ear,  and  thus 
producing  a  circumscribed  inflammation  of  the  external  auditory  canal, 
with  occasional  involvement  of  the  membrana  tympani,  or  even  local 
abscess-formation:  a  condition  of  far  less  frequent  occurrence  and  of 
much  less  significance  than  the  involvement  of  the  middle  ear. 

The  frequency  with  which  this  complication  arises  varies  with  the 


194  THE    ACUTE    EXANTHEMATA. 

character  of  the  epidemic,  and  to  a  certain  degree  with  the  age  of  the 
individual  attacked.  As  a  rule,  it  can  be  said  that,  the  younger  the 
child,  the  greater  is  the  danger  of  otitis,  the  liability  diminishing  with 
each  added  year.  The  mild  or  catarrhal  form  of  otitis  media,  accord- 
ing to  Bader  and  Guinon,307  is  very  common,  occurring  in  33  per  cent, 
of  all  cases  of  scarlet  fever,  while  the  purulent  form  is  less  common, 
occurring  in  but  4.5  per  cent.  In  Cadger's308  analysis  of  4015  cases  of 
scarlatina  the  percentage  given  for  the  occurrence  of  otitis  media  with 
discharge  is  11.05.  That  it  is  much  more  frequent  in  cases  accom- 
panied by  severe  throat  symptoms  must  be  admitted.  Holt309  places 
its  occurrence  as  high  as  75  per  cent,  in  the  severe  cases.  It  may  de- 
velop at  any  time  during  the  scarlatinal  attack,  after  the  first  two  or 
three  days,  and  in  cases  accompanied  with  marked  involvement  of  the 
pharynx  very  commonly  appears  about  the  end  of  the  first  week.  As 
a  rule,  when  one  ear  is  affected,  the  other  side  does  not  escape,  although 
both  ears  are  not  affected  simultaneously. 

In  many  cases  when  it  develops  at  the  height  of  the  disease,  and 
particularly  in  young  children,  there  is  danger  of  its  being  overlooked 
during  the  early  stages,  and  it  often  happens  that  it  is  not  until  the 
appearance  of  the  discharge  from  the  external  ear  that  the  existence 
of  this  complication  is  discovered.  Frequently  children  may  excite 
suspicion  through  their  cry,  or  by  repeatedly  carrying  their  hands  to 
the  head,  but  only  in  an  indefinite  way;  while,  again,  many  small 
children  give  no  such  clue,  and  even  in  older  children,  with  the  ab- 
sence of  marked  pain,  the  accompanying  deafness  may  escape  notice, 
and  the  unusual  duration  of  or  unexpected  rise  in  the  temperature 
may  be  the  first  indication  of  the  local  trouble. 

Coincident  with  the  extension  of  the  inflammation  from  the  phar- 
ynx along  the  Eustachian  tube,  there  occurs  marked  congestion  and 
swelling  of  the  mucous  membrane  of  this  canal,  resulting  in  occlusion 
of  its  lumen,  which  prevents  the  escape  of  any  exudate  formed,  thus 
giving  rise,  in  a  large  measure,  to  the  resulting  symptoms. 

These  are  evidenced,  early  in  the  attack,  by  pain  in  the  affected 
ear,  tenderness  over  and  about  the  external  auditory  canal,  slight  or 
marked  rise  in  the  temperature,  or  persistence  of  the  existing  tem- 


107  See  Moizard:  "Scarlatine,"  in  "Trajt6  des  Mai.  de  1'Enfance"  (Paris    1897)    vol 
i.  p.  143. 

**Caiger  (F.  F.):  "Scarlet  Fever,"  in  Allbutt's  "System  of  Medicine"  (New  York 
1897),  vol.  iii,  p.  150. 

"•Holt  (L.  E.):  "Diseases  of  Infancy  and  Childhood"  (New  York,  1897),  p.  101. 


SCARLATINA.  195 

perature  curve.  The  lymphatic  glands  in  the  immediate  neighborhood 
of  the  ear  are  enlarged,  palpable,  and  may  be  tender. 

These  symptoms  persist  for  three  or  four  days,  when,  unless  re- 
lieved by  incision,  the  membrana  tympani  ruptures  spontaneously,  fol- 
lowing which  there  is  often  seen  an  immediate  and  marked  improve- 
ment, the  pain  and  tenderness  disappearing,  while  the  fever  quickly 
subsides.  In  the  less  severe  cases  the  rupture  or  incision  of  the  tympanic 
membrane,  with  the  escape  of  the  contents  from  the  middle  ear,  marks 
the  turning-point  in  the  affection,  which  then,  under  appropriate  treat- 
ment, improves  slowly,  the  discharge  ceasing  after  three  or  four  weeks, 
while  the  incision  in  the  membrana  tympani  heals  rapidly,  without 
marked  disturbance  of  hearing. 

In  those  instances  in  which  the  inflammation  of  the  middle  ear 
becomes  purulent  ("suppurative  otitis  media")  the  condition  is  one  of 
great  seriousness,  the  result  being  all  too  frequently  total  deafness. 
This  complication  is  seen  in  the  severe  types  of  scarlatina  associated 
with  grave  scarlatinal  angina,  while  the  subjective  symptoms  remain 
as  in  the  simple  form,  with  an  added  irregularity  in,  or  unusual  eleva- 
tion of,  the  temperature  curve.  Externally,  early  examination  reveals 
a  marked  injection  of  the  blood-vessels  of  the  tympanic  membrane. 
The  membrane  itself  becomes  swollen,  cloudy,  and  of  a  yellowish-red 
color;  its  edges  cannot  be  sharply  defined,  the  handle  of  the  malleus 
is  obscured,  and  there  is  even  swelling  and  injection  of  the  deeper  parts 
of  the  external  auditory  canal.  Unless  relieved  by  prompt  incision, 
perforation  occurs  in  from  two  to  three  days,  with,  in  some  instances, 
immediate  improvement  of  the  symptoms.  In  many  cases,  however, 
the  inflammatory  process  is  of  such  an  extreme  grade  that  total  deaf- 
ness results,  with  the  establishment  of  a  chronic  otorrhoea,  which  may 
lead  to  subsequent  serious  complications.  The  amount  of  destruction 
which  follows  suppurative  otitis  varies  from  partial  loss  of  the  tym- 
panic membrane,  with  greatly  diminished  hearing  on  one  or  both  sides, 
to  complete  destruction  of  the  membrana  tympani,  together  with  one 
or  more  of  the  bones  of  the  tympanic  cavity,  and  extensive  ulceration 
or  even  necrosis  of  the  tympanum.  As  a  result  of  chronic  otorrhoea, 
inflammation  of  the  mastpid  cells,  paralysis  of  the  facial  nerve,  sinus- 
thrombosis,  meningitis,  and  even  abscess  of  the  brain  may  ensue. 

Of  85  cases  of  ear  disease  resulting  from  scarlet  fever,  Burckhardt- 
Merian310  found  both  ears  affected  in  72  cases  (84.7  per  cent.),  and, 

810  Burckhardt-Merian:  "Ueber  den  Scharlach  in  seinen  Beziehungen  zum  Gehor- 
organ."  Von  Volkmann's  Klinisch.  Vortrage,  No.  182  (Chirurgie,  No.  54),  p.  1489. 


196  THE    ACUTE    EXANTHEMATA. 

further,  among  4309  cases  of  acquired  deafness,  444  (10.3  per  cent.) 
were  referable  to  scarlet  fever. 

Empyema  of  the  mast-old  antrum,  as  a  result  of  chronic  suppura- 
tive  otitis  media,  occurs  in  a  small  percentage  of  all  cases.  With  the 
establishment  of  a  communication  between  the  tympanic  cavity  and 
the  cells  of  the  mastoid,  there  is  usually  a  slight  decrease  in  the  amount 
of  the  discharge  from  the  ear,  the  temperature  rises  to  104°  F.  or 
higher,  and  shows  a  more  marked  fluctuation.  There  is  pain  referred 
to  the  mastoid  region,  with  tenderness,  more  or  less  pronounced,  over 
the  mastoid  process.  There  may  be  a  slight  rigor.  The  pulse  becomes 
rapid,  and  may  be  irregular,  while  there  is  commonly  great  restless- 
ness and  irritability.  These  symptoms  persist,  with  varying  intensity, 
from  day  to  day,  and,  unless  relieved  by  operation,  these  cases  may 
end  fatally,  due  to  the  development  of  meningitis. 

More  rarely  an  inflammatory  swelling  appears  behind  the  external 
ear,  situated  over  the  mastoid,  associated  with  a  rise  of  temperature, 
extreme  local  tenderness,  and,  in  a  certain  number  of  cases,  oedema  of 
the  eyelids  on  the  same  side,  with  more  or  less  projection  forward  of 
the  ear;  and,  occasionally,  actual  local  suppuration  and  abscess-forma- 
tion takes  place.  This  is  due  either  to  a  periostitis  or  a  local  adenitis, 
which  may  be  remotely  dependent  upon  the  otitis  media. 

The  Lymphatics.  Phlegm-onotis  Inflammation  of  the  Neck.  Diffuse 
CeUulitis.  Angina  Ludovici  ("Tippet  Neck"). — The  enlargement  of 
the  lymphatic  glands  of  the  neck  is  usually  marked  early  in  the  course 
of  scarlatina,  the  increase  in  size  of  the  maxillary  and  submaxillary 
glands  being  particularly  constant,  indeed,  occurring  in  95  and  36  per 
cent.,  respectively,  of  all  cases  of  scarlet  fever.311  The  posterior  cervical 
glands,  while  showing  some  enlargement  in  77  per  cent.,  never  attain 
any  great  size,  dnd,  owing  to  their  situation,  play  but  an  unimportant 
role.  In  cases  of  moderate  severity  the  enlargement  of  the  lymphatic 
glands  never  reaches  an  extreme  degree,  and,  with  the  establishment 
of  convalescence,  resolution  sets  in.  In  the  more  severe  forms  of  scar- 
latina— those  particularly  characterized  by  early  and  intense  involve- 
ment of  the  pharynx — the  swelling  of  the  neighboring  lymphatic 
glands  may  be  extreme.  They  become  tense,  hard,  and  resistant,  and 
may  even  reach  such  a  degree  of  enlargement  as  to  interfere  with  the 
movements  of  the  head.  In  some  instances  the  parotid  glands,  as  well, 


811  Schamberg  (J.  F.):  "A  Clinical  Study  of  the  Lymphatic  Glands  in  One  Hundred 
Cases  of  Scarlet  Fever."  Ann.  of  Gynecology  and  Pediat.  (Boston),  December,  1889,  vol. 
xiii,  p.  39. 


SCARLATINA.  197 

are  involved.  In  not  a  few  cases  the  enlargement  of  the  maxillary 
and  submaxillary  glands  persists,,  and,  passing  beyond  the  first  stage  of 
inflammation,  suppuration  occurs,  giving  rise  to  the  so-called  phleg- 
monous inflammation. 

Phlegmonous  Inflammation.  —  The  resulting  maxillary  and  sub- 
maxillary  abscesses  constitute  always  a  serious  complication,  and,  un- 
less opened  and  drained,  may  lead  to  haemorrhages  from  the  large  ves- 
sels of  the  neck.  Even  when  freely  incised  there  is  always  danger  of 
the  pus  burrowing  beneath  the  connective  tissue,  and  giving  rise  ulti- 
mately to  some  unlooked-for  and  added  complication.  In  other  in- 
stances there  may  develop,  coincidently  with  or  immediately  follow- 
ing the  suppurative  process,  a  rapid  and  diffuse  cellulitis,  with  ex- 
cessive infiltration  of  the  deeper  tissues  of  this  region. 

Angina  Ludovici  ("Tippet  Neck"). — This  may  occur  by  the  fifth 
day  of  the  disease,  though  more  commonly  it  is  seen  early  in  the 
second  week  of  the  attack.  The  skin  is  indurated,  tense,  and  glossy, 
and  may  pit  on  pressure,  though  giving  no  sense  of  fluctuation. 
The  process  may  be  limited  to  the  angles  of  the  jaw  or  involve  the 
entire  neck;  it  may  extend  downward  to  the  clavicles  and  upward 
along  the  sides  of  the  face  and  head,  rendering  the  head  almost,  if  not 
wholly,  rigid.  Associated  with  the  phlegmonous  inflammation  of  the 
lymphatic  glands  in  the  neck,  this  diffuse  cellulitis  of  the  deeper  tis- 
sues constitutes  one  of  the  gravest  complications  of  scarlet  fever,  prov- 
ing almost  invariably  fatal.  Death  results  from  a  rupture  of  one  of 
the  large  vessels, — jugular  vein  or  internal  carotid  artery, — or  as  a  re- 
sult of  thrombosis  or  embolism,  with  fatal  meningitis  or  pyaemia. 

The  involvement  of  the  superficial  lymphatic  glands,  as  well  as 
of  all  the  lymphatic  tissues  of  the  body  in  scarlet  fever,  depends  upon 
the  character  and  the  intensity  of  the  infection,  being  more  pronounced 
in  cases  of  extreme  toxaemia,  though  present  in  a  less  degree  in  the 
milder  types  of  the  disease. 

That  the  scarlatinal  virus  alone  is  capable  of  giving  rise  to  great 
enlargement  and  even  actual  hyperplasia  of  the  lymphatic  structures, 
not  only  of  the  lymphatic  glands,  but  of  the  single  and  agminated  fol- 
licles Us  well,  is  clearly  established  by  the  changes  seen  in  those  cases 
which,  succumbing  early  in  their  course  to  the  severity  of  the  scar- 
latinal infection,  show  post-mortem  a  marked  increase  and  prolifera- 
tion of  all  the  lymphatic  tissues,  with  little  or  no  other  marked  patho- 
logical alteration.312  The  spleen  in  scarlet  fever  is  frequently  enlarged 

312  See  von  Jurgensen  (loc.  cit.,  pp.  70-80,  Cases  II  to  VI). 


198  THE    ACUTE    EXANTHEMATA. 

and  readily  palpable  at  the  margin  of  the  ribs,  and  may  even  attain 
early  in  the  attack  double  its  normal  size,  while,  with  the  existence  of 
a  secondary  infection,  as  would  be' expected,  it  may  be  greatly  increased 
in  size. 

Though  the  enlargement  of  the  superficial  lymphatic  glands  in- 
cludes all  those  groups  readily  palpable,  it  is  most  constantly  seen  in 
the  glands  situated  beneath,  and  at  the  angle  of,  the  jaw,  giving  rise, 
in  many  cases,  as  noted  above,  to  extreme  glandular  infiltration,  and 
even  suppuration,  being  particularly  marked  in  those  cases  associated 
with  severe  throat  symptoms  (phlegmonous  inflammation,  angina 
Ludovici).  The  enlargement  may  be  unilateral;  more  commonly  it  is 
bilateral,  and  varies  in  size  from  a  small,  readily  palpable  mass,  meas- 
uring about  an  inch  (2  to  3  centimetres)  in  diameter  to  a  large  tumor 
of  about  two  inches  (4  to  5  centimetres)  in  diameter,  or  larger. 

Following  the  excessive  suppuration  of  the  lymphatic  glands  of 
the  neck,  and  as  a  direct  sequence,  conjunctivitis,  necrosis  of  the 
cornea,  and  even  destruction  of  the  entire  bulb  may  ensue.  In  addi- 
tion, erosions  into  the  large  vessels  of  the  neck,  phlebitis  with  the  for- 
mation of  thrombi,  and  rarely  direct  openings  into  the  pharynx,  or  a 
retropharyngeal  abscess  are  among  the  complications.  Bokai313  has 
recorded  six  cases  of  retropharyngeal  abscess  as  a  result  of  lymphade- 
nitis, out  of  664  cases  of  scarlet  fever. 

In  a  recent  study  of  the  lymphatic  glands  in  scarlatina,  Scham- 
berg  (loc.  cit.)  found  that  the  various  groups  of  lymphatic  glands  were 
enlarged  in  the  following  proportion  in  a  hundred  cases: — 

Inguinal  glands    100  per  cent. 

Axillary    96  "  " 

Maxillary   95  "  " 

Posterior  cervical    77  "  " 

Anterior  cervical    44  "  " 

Submaxillary     36  "  " 

Epitrochlear    26  "  " 

Sublingual   25  "  " 

As  a  result  of  the  analysis  of  these  hundred  cases  he  finds  that 
the  maxillary  glands  commonly  attain  the  largest  size,  and  also  most 
frequently  undergo  suppuration.  In  all  cases  examined  on  the  second 
and  third  day  of  the  disease  the  enlargement  of  the  lymphatic  glands 
was  well  marked. 


m  B6kai    (J.,    Sr.):    "Ueber   Retropharyngealabscesse    bei   Kindern."     "Jahrb.    f. 
Kindh.,  N.  F.,"  vol.  x,  pp.  108  et  aeq. 


SCARLATINA.  199 

Involvement  of  the  J-oints. — Acute  articular  rheumatism  may  occur 
coincidently  with  the  development  of  an  attack  of  scarlet  fever,  though 
more  frequently  it  is  seen  as  a  complication  arising  during  convales- 
cence, and  differs  in  no  way  from  an  ordinary  attack  of  rheumatism  un- 
complicated by  scarlatina.  An  attack  of  scarlet  fever  during  convales- 
cence from  rheumatism  frequently  causes  a  relapse  of  the  rheumatic 
affection. 

Scarlatinal  synovitis  (so-called  scarlatinal  rheumatism,  or  "pseudo- 
rheumatism")  is  a  comparatively  common  complication  of  scarlet  fever, 
showing,  however,  a  great  variation  in  the  frequency  of  its  occurrence 
in  different  epidemics.  In  a  series  of  500  cases  of  scarlatina  reported 
by  Ashby314  there  were  but  10  mild  cases,  or  2  per  cent.,  and  but  2 
severe  cases.  In  3000  cases  of  scarlet  fever  Hodger315  noted  117  cases 
of  scarlatinal  synovitis,  or  3.2  per  cent.  There  has  long  been  a  great 
difference  of  opinion  as  to  the  exact  nature  of  this  affection,  but,  ac- 
cording to  the  commonly  accepted  view  of  the  present  day,  it  is  held 
that  it  is  not  identical  with  true  articular  rheumatism,  being  regarded 
as  an  independent,  pseudorheumatic  infection,  differing  clinically  from 
the  former  in  that  it  shows  less  tendency  to  migrate  from  joint  to  joint, 
while,  ordinarily,  fewer  joints  are  involved.  Furthermore,  the  charac- 
teristic acid  sweats  of  true  rheumatism  are  absent,  relapses  are  less  fre- 
quent, its  occurrence  in  individuals  with  a  distinct  rheumatic  history 
is  not  more  frequent,  and  the  cardiac  complications  which  follow  gen- 
uine rheumatism  are  much  less  common.  Two  distinct  forms  may  be 
recognized:  (a)  simple  catarrhal  or  serous  synovitis,  and  (b)  suppura- 
tive  or  purulent  arthritis  (a  condition  of  far  greater  rarity  than  the 
simple  form).  The  streptococcus  pyogenes  has  been  found  in  both 
forms  in  pure  culture,  and  occasionally  in  combination  with  other 
micrococci. 

Simple  scarlatinal  synovitis  is  seen  more  often  in  young  adults 
than  in  infants  and  children,  increasing  in  frequency  after  the  fifth 
year  and  occurring  but  rarely  under  the  age  of  three  (Holt,  loc.  cit.,  p. 
902).  Any  of  the  joints  may  be  attacked,  though  the  small  joints, 
particularly  those  of  the  hands  and  wrists  and  of  the  ankles  and  feet, 
are  involved  more  frequently  than  the  larger  articulations. 

In  rare  instances  the  cervical  vertebras  are  invaded,  giving  rise, 
in  some  cases,  to  contractures  of  the  cervical  muscles.  It  occurs  usu- 
ally at  the  end  of  the  first,  or  beginning  of  the  second,  week,  while, 

su  Ashby,  H.:  Brit.  Med.  Jour.,  1883,  vol.  ii,  p.  514. 
316  Hodger:  See  Eichhorst  (loc.  cit.,  p.  241). 


200  THE   ACUTE    EXANTHEMATA. 

at  other  times,  it  may  not  develop  until  late  in  the  second,  or  early  in 
the  third,  week  of  the  disease.  The  symptoms  referable  to  the  mildest 
forms  are:  vague  pains  in  the  affected  joints;  swelling,  which  may  or 
may  not  be  marked,  with  but  slight  impairment  of  motion;  some  red- 
ness, and  occasionally  a  slight  rise  of  temperature.  As  a  rule,  these 
symptoms  persist  for  from  three  to  four  days,  and  then  disappear  en- 
tirely. In  more  severe,  but  exceptional,  cases,  the  pain,  swelling,  red- 
ness, and  immobility  of  the  joint  may  be  extreme  and  associated  with 
high  fever,  and  more  pronounced  constitutional  disturbance. 

In  a  few  cases  the  large  joints  (knee  or  shoulder)  may  remain 
swollen  for  some  weeks,  owing  to  the  effusion  of  serum.  According  to 
von  Jiirgensen  (loc.  cit.,  p.  161),  the  constant  uniformity  of  the  local 
process  in  the  involved  joint,  which  persists  steadily  while  the  attack 
lasts  and  shows  no  such  fluctuation  as  is  seen  in  true  articular  rheuma- 
tism, is  peculiarly  characteristic  of  scarlatinal  synovitis. 

Suppurative  synovitis,  or  arthritis,  as  a  complication  of  scarlatina, 
usually  developing  late  in  the  course  of  the  disease  and  involving  the 
large  joints,  is  of  extremely  rare  occurrence,  but  may  arise,  according 
to  Henoch  (Vor.,  loc.  cit.,  p.  658),  either  through  the  local  develop- 
ment of  suppuration  in  the  involved  joint, — the  least  frequent  form, — 
remaining,  in  these  cases,  limited  to  a  single  joint;  or  as  the  result  of 
emboli,  following  septicaemia,  involving  a  number  of  joints  and  always 
resulting  in  death.  The  commonest  source  of  the  septicaemia  in  these 
cases  is  the  ulcerative  and  necrotic  processes  in  the  pharynx. 

Bokai316  has  seen  the  local  process  following  a  scarlatinal  arthritis 
become  chronic,  with  resulting  so-called  "white  swelling"  of  the  joints: 
a  secondary  tuberculous  infection,  occurring  as  a  sequela  of  the  scar- 
latinal inflammation.  Exceptionally,  the  larger  joints  may  be  further 
involved  by  the  development  of  periarticular  abscesses,  which  may  lead 
subsequently  to  a  communication  into  the  joint-cavity. 

Instances  of  marked  ankylosis,  and  even  deformity,  following  scar- 
latina,— affecting  the  ankles,  knee,  elbow,  and  phalangeal  joints, — are 
reported  in  literature.317 

Involvement  of  the  Kidneys. — N"o  complication  of  scarlatina  is  more 
uncertain,  and  at  the  same  time  more  grave  from  the  stand-point  of  its 
possible  results,  than  the  occurrence  of  nephritis,  while  as  a  factor  in 
the  development  of  acute  nephritis,  particularly  in  childhood,  scarlet 

S1«  B6kai  (J.,  Jr.):  "Ueber  die  Scarlatinosen  Gelenkentzundungen."  "Jahrb.  f. 
Kindh.,  N.  P.,"  vol.  xxhi,  1885,  pp.  304  et  seq. 

817  Richardiere  et  Peron:  See  soc.  proceed.  Gaz.  des  H6p.,  December  5,  1893,  p.  1318. 


SCARLATINA.  201 

fever  is  the  most  important,  no  case,  however  mild,  being  wholly  free 
from  the  danger  of  a  subsequent  serious  renal  inflammation. 

Clinically,  we  may  differentiate  the  conditions  arising  as  a  result 
of  the  involvement  of  the  kidneys,  into  three  groups: — 

1.  Transient  febrile  albuminuria,  and  the  initial  catarrhal  nephri- 
tis. 2.  Septic  nephritis.  3.  Post-scarlatinal  nephritis. 

The  presence  of  a  transient  albuminuria  early  in  the  course  of  scar- 
latina is  of  very  frequent  occurrence,  being  seen  in  from  77.6  to  92 
per  cent,  of  all  cases.318  In  the  vast  majority  of  instances  it  differs  in 
no  way  from  the  febrile  albuminuria  seen  in  all  acute  infections  asso- 
ciated with  more  or  less  elevation  of  temperature.  It  appears  usually 
on  the  second  or  third  day,  lasts  but  three  or  four  days,  and  disappears 
at  the  end  of  the  first  week,  with  the  subsidence  of  the  fever.  This 
complication  is  of  no  especial  significance,  as  it  does  not  depend  on 
any  pathological  alteration  in  the  structure  of  the  kidneys. 

Initial  catarrhal  nephritis  not  infreqiiently  occurs  in  the  first  week, 
in  cases  of  moderate  severity:  i.e.,  in  contradistinction  to  those  which 
prove  fatal  within  the  first  two  or  three  days.  The  urine,  in  addition 
to  the  presence  of  albumin,  shows,  microscopically,  degenerated  epithe- 
lial cells,  mucous  cylindroids,  and,  in  rare  instances,  epithelial  or  even 
hyaline  casts,  with  occasionally  a  few  red  and  white  blood-corpuscles. 
Jn  addition  to  these  microscopical  findings,  Friedlander319  has  noted 
clinically,  in  a  few  exceptional  instances,  slight  traces  of  oedema.  These 
symptoms  have  been  interpreted  as  evidence  of  an  early  catarrhal  in- 
flammation— "acute  degenerative  nephritis" — of  the  tubules  of  the 
kidney,  and  are  very  commonly  first  detected  at  the  time  of  the  appear- 
ance of  the  eruption.  They  are  usually  of  a  mild  character,  and  with 
the  fall  of  temperature,  and  fading  of  the  rash,  may  disappear  alto- 
gether during  the  second  week,  so  far,  at  least,  as  the  microscopical 
evidence  of  the  urine  is  concerned.  In  every  such  case  when  one  finds 
traces  of  even  a  mild  degree  of  catarrhal  or  degenerative  alteration,  the 
possibility  of  its  continuance  up  to  the  time  of  the  appearance  of  a 
true  post-scarlatinal  nephritis  should  not  be  lost  sight  of.  It  is,  natu- 
rally, impossible  to  determine  how  much,  or  how  little  damage  may 
have  taken  place  in  any  individual  instance.  That  we  may  have,  rarely, 
actual  pathological  alteration  slowly  going  on,  without  a  trace  of  albu- 
min, or  without  the  evidence  afforded  by  casts,  is  definitely  established 
by  a  number  of  reported  instances.  In  cases  which  succumb  to  the 

318  See  Eichhorst  (loc.  cit.,  p.  239). 

319  Friedlander  (C.):  Fortschritte  der  Med.,  1883,  vol.  i,  p.  81. 


202  THE   ACUTE   EXANTHEMATA. 

scarlatinal  infection  within  the  first  two  or  three  days,  more  or  less 
marked  anatomical  alteration  in  the  kidneys  is  frequently  observed; 
but,  as  these  results  are  known  to  often  depend  on  exceptionally  grave 
toxaemia,  or  some  intercurrent  complication,  it  is  not  possible  to  draw 
definite  conclusions  from  them.  In  the  great  majority  of  cases  com- 
plicated by  a  post-scarlatinal  nephritis,  the  early  catarrhal  inflamma- 
tion, when  present,  subsides  entirely,  being  followed  by  a  period  dur- 
ing which,  so  far  as  we  can  determine  by  examination  of  the  urine,  no 
active  change  is  taking  place.  Again,  less  often,  the  early  inflamma- 
tory change  may  continue  throughout  the  course  of  the  attack,  though 
in  a  mild  form,  up  to  the  time  when  the  symptoms  of  late  renal  in- 
volvement make  their  appearance. 

Septic  Nephritis. — In  a  small  number  of  cases  characterized  by  an 
overwhelming  intoxication  by  the  scarlatinal  virus,  and  associated 
usually  with  grave  throat  symptoms,  pseudomembranous  inflammation, 
ulceration,  and  involvement  of  the  lymphatic  glands,  there  may  de- 
velop during  the  first,  or  early  in  the  second,  week  a  severe  nephritis 
as  a  direct  result  of  the  intensity  of  the  infection,  which  is  commonly 
in  these  cases  a  "mixed  one,"  the  streptococcus  pyogenes  being  an 
added  factor  in  the  etiology  of  the  renal  inflammation.  Not  infre- 
quently the  symptoms  are  so  masked  by  the  malignancy  of  the  attack, 
that  the  existence  of  a  nephritis  is  not  discovered  until  after  death. 
There  is  no  dropsy,  and  uraemic  symptoms  are  absent,  while  the  urine, 
which  may  show  the  presence  of  albumin  in  greater  or  less  amount, 
usually  without  the  co-existence  of  casts  or  of  blood,  may,  in  rare  in- 
stances, be  normal  during  the  entire  course  of  the  attack.  The  con- 
dition is  one  of  profound  septicaemia,  and,  although  the  evidence  of 
renal  involvement  may  be  wholly  absent,  the  kidneys  reveal  marked 
pathological  alteration  after  death. 

Post-scarlati-nal  Nephritis. — The  occurrence  of  post-scarlatinal 
nephritis,  by  which  is  meant  a  nephritis  developing  after  the  subsidence 
of  the  acute  symptoms  of  the  disease,  varies  greatly  in  different  epi- 
demics, only  emphasizing  in  its  very  uncertainty  the  peculiar  charac- 
teristics of  the  disease  or  the  varying  susceptibility  of  the  individual. 
It  has  been  shown  elsewhere  that  the  nephritis  developing  after 
the  acute  stage  is  by  no  means  always  purely  glomerular,  though, 
with  the  advancement  of  convalescence  the  frequency  of  this  form, 
anatomically  at  least,  increases.  In  Friedlander's  series  it  was  present 
in  18  per  cent.  Cadet  de  Gassicourt320  has  noted  the  occurrence  of 

420  See  Moizard  (foe.  cit.,  p.  148). 


SCARLATINA.  203 

a  late  scarlatinal  nephritis  in  30  per  cent,  of  all  cases.  Ashby321  finds 
that,  taking  the  average  of  several  years,  about  6  per  cent,  of  his  hos- 
pital patients  developed  a.  post-scarlatinal  nephritis.  Caiger  (loc.  cit., 
p.  156),  in  a  series  of  2078  cases,  gives  the  frequency  of  "acute  nephri- 
tis" as  3.32  per  cent.  It  is  manifestly  impossible  to  determine  early  in 
the  course  of  the  attack  whether,  in  a  given  case  of  scarlet  fever 
nephritis  may  or  may  not  occur,  a  mild  case  of  the  disease  being  fol- 
lowed, in  many  instances,  by  severe  renal  involvement,  while,  again,  a 
*  most  severe  attack  may  escape.  As  a  general  rule,  however,  it  can  be 
said  that,  the  severer  the  type  of  the  infection,  the  greater  is  the  danger 
of  a  subsequent  nephritis. 

The  views  advanced  by  some  of  the  older  writers322 — that  every 
case  of  scarlatina  is  accompanied  by  a  catarrh  of  the  renal  tubules,  or 
that  the  involvement  of  the  kidneys'  is  but  the  peculiar  localization  of 
the  specific  poison,  an  essential  "'symptom"  of  the  disease — are  no 
longer  tenable.  The  opinion  held  by  the  early  pathologists,  of  a  recip- 
rocal relationship  between  the  functions  of  the  skin  and  the  kidneys 
in  scarlatina,  is  interesting.  They  assigned  to  the  skin  the  primary 
role  in  the  elimination  of  the  poison  circulating  in  the  blood,  as  shown 
by  the  intense  efflorescence  and  abundant  desquamation,  and  held  that, 
if  not  present,  certain  renal  changes  developed  from  an  effort  on  the 
part  of  the  kidneys  to  eliminate  the  poison,  thus  giving  rise  to  a 
nephritis,  which,  occurring  commonly  with  beginning  desquamation, 
was  believed  to  be  essentially  a  complication  of  this  stage. 

The  weight  of  evidence  points  to  the  view  commonly  held  to-day, 
that  the  occurrence  of  nephritis  during  the  course  of  scarlet  fever  is 
due  to  the  circulation  in  the  blood  of  the  specific  virus,  or  toxin,  which, 
eliminated  by  the  kidneys,  acts  as  a  direct  inflammatory  irritant  in 
greater  or  less  degree  in  each  individual  case.  In  this  connection  the 
view. held  by  von  Jiirgensen  (loc.  cit.,  p.  180),  that  the  effect  of  the 
inflammatory  irritant  depends  not  only  upon  its  virulence  (toxicity), 
but  upon  the  length  of  time  during  which  it  acts  upon  a  given  local 
site,  is  extremely  interesting  and  important.  In  many  instances  the 
course  of  the  nephritis  is  a  variable  one,  improvement  in  the  symptoms 
alternating  with  evidences  of  more  serious  disturbances.  In  such  cases 
the  conclusion  that  the  specific  scarlatinal  virus  is  itself  the  cause, 
whether  present  in  the  blood  in  increased  amount  or  in  increased  tox- 
icity, is  certainly  suggestive.  The  early  slight  inflammatory  changes 

321  Ashby  and  Wright:  "Diseases  of  Children"  (New  York,  1896),  p.  365. 

322  See  Thomas  (loc.  cit.,  p.  247). 


204  THE    ACUTE    EXANTHEMATA. 

are,  according  to  this  view,  due  to  the  same  local  irritation  which,  under 
varying  conditions,  may  produce  the  more  pronounced  alterations  seen 
later  in  the  course  of  the  disease.  That  external  conditions  have  little 
or  no  influence  upon  the  occurrence  of  nephritis  in  scarlatina  is  borne 
out  by  the  evidence  of  many  observers;  and  particularly  is  this  true 
of  the  influence  of  cold,  or  of  "catching  cold/'  to  which  many  cases 
of  scarlatinal  nephritis  were  formerly  attributed.  Mayr  (loc.  cit.,  p. 
207),  writing  in  1864,  had  seen  no  untoward  results  from  exposure  to 
the  severest  weather. 

Henoch  does  not  share  the  belief,  still  held  by  some,  that  there 
is  any  connection  between  suppressed  perspiration  or  exposure  to  cold 
and  the  scarlatinal  nephritis,  almost  all  his  cases  having  developed  in 
spite  of  every  precaution  (loc.  cit.,  p.  587).  Unnecessary  exposure  in 
any  case  would,  none  the  less,  be  ill  advised. 

Age  exerts  but  little  influence  upon  its  occurrence,  though  it  is  less 
common  in  young  adults  than  in  childhood.  Males  and  females  are 
affected  about  equally  up  to  the  age  of  puberty,  after  which  time  there 
is  a  slight  increase  in  favor  of  males.  As  a  rule,  the  first  active  indica- 
tions of  scarlatinal  nephritis  develop  late  in  the  first,  or  early  in  the 
second,  week,  appearing  at  any  time  from  the  twelfth  up  to  the  twenty- 
first  day  of  the  attack,  exceptionally  later. 

In  a  certain  percentage  of  cases  there  develops  at  this  time  a 
simple  albuminuria,  which,  unassociated  with  any  additional  changes  in 
the  urine,  or  with  other  symptoms,  lasts  but  a  few  days,  and  then  dis- 
appears entirely.  Again,  it  shows  a  striking  variability.  Examination 
of  the  urine  may  show  the  presence  of  albumin,  while  later  upon  the 
same  day,  or  upon  alternate  days,  it  may  be  absent. 

According  to  Caiger  (loc.  cit.,  p.  151),  this  albuminuria  occurs  in 
1.28  per  cent,  of  all  cases  of  scarlet  fever,  and  is  interpreted  by  him, 
and  by  Henoch  also,  as  the  mildest  expression  of  the  same  process  seen 
in  the  acute  scarlatinal  nephritis. 

The  onset  of  a  true  post-scarlatinal  nephritis  may  be  sudden  and 
abrupt,  though,  as  is  more  often  the  case,  if  careful  and  repeated  ex- 
aminations of  the  urine  have  been  made  daily,  and  the  amount  secreted 
has  been  accurately  recorded,  there  will  be  found  a  gradual,  though 
marked,  diminution  in  the  quantity  of  urine  secreted  during  the 
twenty-four  hours,  together  with  the  presence  of  a  variable  amount  of 
albumin,  befere  the  appearance  of  the  cloudy,  smoky  urine  and  the 
clinical  symptoms  characteristic  of  the  acute  attack. 

Following  the  subsidence  of  the  initial  temperature  to  normal  or 


SCARLATINA.  205 

thereabouts,  the  child,  who  has  seemed  apparently  well,  on  the  road 
to  convalescence,  becomes  pale,  is  restless  or  irritable,  and  complains 
of  headache,  thirst,  and  loss  of  appetite.  Constipation  may  be  present, 
or  one  or  more  attacks  of  vomiting  may  precede  the  acute  symptoms 
of  renal  trouble.  The  pulse  early  in  the  attack  is  quickened,  while 
later,  and  especially  when  complicated  by  uraemia,  it  becomes  slower 
and  even  irregular,  and  throughout  the  course  of  the  attack  the  tension 
is  greatly  increased.  The  temperature  may  show  a  slight  initial  rise 
of  y2  to  1  degree,  rarely  more,  which  persists  for  a  few  days. 

The  urine  becomes  scanty,  of  a  smoky  tinge,  and  when  allowed  to 
stand  deposits  a  dark  reddish-yellow  precipitate,  while  albumin  is  pres- 
ent in  marked  degree.  Among  the  earliest  evidences  of  a  threatened 
nephritis  many  writers  lay  great  stress  upon  a  slight  rise  of  tempera- 
ture following  the  normal,  considering  a  rise  of  even  1/2  degree  as  of 
especial  significance.  The  occurrence  of  oedema,  however  slight,  is  an 
invariable  indication  of  threatened  trouble,  and  yet  it  may  rarely  be 
absent  during  the  entire  course  of  the  disease  (Henoch).  When  pres- 
ent, it  is  usually  seen  first  as  a  slight  puffiness  of  the  eyes,  involving 
particularly  the  lower  eyelids  and  their  immediate  neighborhood.  It 
may  be  present  early  upon  the  dorsum  of  the  feet,  or  upon  the 
knuckles,  varying  in  amount  from  day  to  day.  In  other  cases  its  de- 
velopment is  extreme,  the  entire  face  becoming  swollen  and  bloated, 
and  the  feet  and  legs  cedematous,  pitting  readily  on  slight  pressure, 
while  the  scrotum  and  penis  in  the  male  and  the  labia  majora  in  fe- 
males may  be  involved.  In  exceptional  instances  the  skin  and  subcu- 
taneous tissue  of  the  entire  body  may  be  tense,  swollen,  and  cedematous, 
in  rare  cases  the  skin  being  actually  tender,  owing  to  its  extreme  ten- 
sion, while  the  eyelids  can  be  opened  only  with  great  difficulty. 

With  the  development  of  the  early  symptoms  of  nephritis,  as  noted 
above,  the  examination  of  the  urine  is  of  the  greatest  importance. 

The  amount  of  urine  secreted  is  much  diminished,  varying  from  a 
few  cubic  centimetres  in  extreme  cases  to  500  cubic  centimetres  in  the 
twenty-four  hours.  The  reaction  is  usually  acid,  unless  altered  by 
drugs.  The  specific  gravity  ranges  from  1.006  to  1.065,  the  latter  being 
rare,  though  some  of  the  densest  urines  met  with  occur  in  scarlatinal 
nephritis.323  The  amount  of  urea  is  usually  under  2  per  cent.,  often 
little  more  than  1  per  cent.  The  albumin  ordinarily  varies  from  0.05 
to  0.1  per  cent.,  reaching  1  per  cent,  or  even  higher  in  severe  cases. 

323  Saundby  (R.):  "Lectures  on  Renal  and  Urinary  Diseases"  (Philadelphia,  1897), 
p.  101. 


206  THE    ACUTE    EXANTHEMATA. 

The  diazo-reaction  is  of  no  value  in  scarlet  fever;  at  times  it  may  be 
present,  though  more  frequently,  in  the  writer's  experience,  it  is  ab- 
sent. Microscopically,  there  may  be  present  hyaline,  epithelial,  granu- 
lar, and  blood-casts;  fragmented  renal  epithelium;  white  and  red 
blood-corpuscles,  the  latter  in  varying  numbers  in  different  instances; 
uric  acid  and  oxalic  acid  in  crystalline  and  amorphous  form,  and  more 
or  less  granular  debris. 

While  the  above  represents  the  conditions  prevailing  in  an  aver- 
age case  af  acute  scarlatinal  nephritis,  there  may  be  striking  variations 
in  the  urine  from  day  to  day,  or  even  a  wide  variation  in  the  findings 
as  a  whole,  since  it  must  not  be  forgotten  that  nephritis  may  be  pres- 
ent with  but  little,  if  any,  evidence  in  the  urine. 

Cases  characterized  by  a  mild  degree  of  pathological  alteration  in 
the  urine,  and  associated  usually  with  a  moderate  amount  of  oedema, 
not  infrequently  begin  to  improve  early  in  their  course,  and  often, 
after  two  or  three  weeks,  the  renal  symptoms  have  wholly  disappeared; 
at  other  times  the  albuminuria  may  persist  indefinitely,  following  the 
disappearance  of  the  acute  stage  and  rendering  the  patient  liable  to  a 
subsequent  relapse  at  any  time.  In  those  instances  in  which  the  symp- 
toms persist  for  from  six  weeks  to  two  months,  the  condition  not  in- 
frequently becomes  subacute  or  chronic,  and  the  damage  already  done 
may  last  for  years. 

Among  the  added  complications  which  may  arise  during  the  course 
of  a  nephritis,  the  occurrence  of  uraemia  is  of  the  gravest  significance. 
In  rare  cases324  the  first  indication  of  the  developing  nephritis  may  be 
an  abrupt  and  sudden  uraemic  attack.  As  a  rule,  however,  the  evidence 
of  threatened  uraemia  does  not  appear  until  the  existence  of  the  nephri- 
tis has  been  for  some  time  recognized,  and  follows  generally  a  more  or 
less  prolonged  diminution  in  the  amount  of  urine  secreted,  occurring 
more  frequently  in  the  severe  cases,  though  even  mild  cases  are  by  no 
means  exempt. 

The  onset  of  uraemia  may  be  gradual  or  abrupt.  Headache,  vom- 
iting, stupor,  and  the  peculiar  twitchings  of  the  facial  muscles,  or  those 
of  the  hands,  so  characteristic  of  the  condition,  are  usually  the  first 
indications  of  the  coming  attack.  The  pulse  is  slow  and  the  tempera- 
ture may  be  subnormal.  The  tongue  is  dry.  Less  frequently  there  is 
stupor  more  or  less  complete  from  the  first,  the  temperature  is  elevated, 
the  pulse  of  small  volume  and  increased,  the  respirations  are  short  and 


246  et  seq 


See  Henoch   (loc.   cit.,  p.   597);   Leichtenstern:   Deutsche  med.   Woch.,   1882,  pp. 

• 


SCARLATINA.  207 

hurried,  and  the  skin  is  dry.  Convulsions  may  develop,  clonic  in  char- 
acter and  of  varying  intensity,  involving  the  face  and  the  extremities 
as  a  whole,  in  sequence,  or  more  rarely  picking  out  scattered  groups  of 
muscles.  The  urine  and  fasces  may  be  discharged  involuntarily.  •Cya- 
nosis is  marked,  the  pulse  becomes  slow  and  irregular,  and  the  tempera- 
ture falls  rapidly.  Complete  suppression  of  the  urine  follows,  coma 
ensues,  and  in  the  vast  majority  of  instances  characterized  by  these 
grave  symptoms  the  case  ends  fatally. 

Earely,  when  the  patient  has  survived,  attacks  of  mania,  melan- 
cholia, aphasia,  and  amaurosis  have  been  noted  as  sequelae. 

Of  secondary  importance  only  to  uraemia  is  the  development  of  ex- 
cessive oedema,  which,  acquiring  an  extreme  grade  during  the  course 
of  the  nephritis,  may  be  associated  with  general  anasarca,  or  even  with 
the  exudation  of  fluid  into  the  serous  cavities  of  the  body.  This  is  seen 
more  commonly  as  ascites,  following  usually  a  marked  oedema  into  the 
skin  and  subcutaneous  connective  tissue.  Later,  exudation  into  the 
pleura  or  even  into  the  pericardium  may  take  place. 

In  exceptional  instances  the  sudden  development  of  oedema  of  the 
•lungs  leads  to  an  abrupt  and  fatal  end,  while,  more  rarely,  oedema  of 
the  larynx  is  an  added  complication.  The  possibility  of  oedema  of  the 
pia  mater,  and  cerebral  substance,  or  cerebral  ventricles,  is  mentioned 
by  Mayr  (loc.  cit.,  p.  211). 

Heart. — The  great  susceptibility  of  the  heart,  or  of  the  intrinsic 
cardiac  ganglia,  to  the  scarlatinal  poison  is  clearly  demonstrated  by  the 
pronounced  tachycardia — associated  with  the  small,  rapid,  and  even 
irregular  pulse — which  is  seen  early  in  the  attack,  often  before  the  ap- 
pearance of  the  eruption,  more  marked  in  cases  characterized  by  a 
severe  and  sudden  onset. 

Later,  in  the  course  of  the  disease,  the  heart-sounds  may  lose  their 
normal  tone,  the  first  sound  becoming  soft  and  valvular,  or  they  may 
run  together;  so  that  it  is  impossible  to  differentiate  the  two  elements. 
More  rarely  there  may  develop  later  a  marked  bradycardia;  exception- 
ally actual  dilatation  may  be  demonstrated. 

That  these  symptoms  are,  in  many  instances,  but  the  expression 
of  a  mild  myocarditis  due  to  the  scarlatinal  virus  alone  seems  to  have 
been  shown  by  the  careful  observations  of  Romberg.325  In  a  small  per- 
centage of  cases  of  uncomplicated  scarlet  fever  endocarditis  or  pericar- 


325  Romberg  (Ernst):  "Ueber  die  Erkrankungen  des  Herzmuskels  bei  Typhus  ab- 
dominalis,  Scharlach,  und  Dipb.tb.erie."  Deutsche  Archiv  fiir  klin.  Med.,  vol.  xlviii, 
1891,  pp.  369  et  seq. 


208  THE    ACUTE    EXANTHEMATA. 

ditis  also  develops,  and  may  or  may  not  be  evident  from  the  physical 
signs.  In  the  majority  of  cases  the  endocardium  of  the  heart-wall, 
rather  than  of  the  valves,  is  involved.  When,  however,  the  latter  are 
affected,  the  mitral  segments  are  the  most  frequent  seats  of  the  lesion. 

It  has  been  shown  that,  following  acute  scarlatinal  nephritis,  there 
is  in  children,  and,  to  a  much  less  extent,  in  adults,  an  almost  constant 
acute  dilatation  and  hypertrophy  of  the  heart,  affecting  chiefly  the  left 
ventricle.  This  dilatation  and  hypertrophy,  occurring  as  a  result  of 
the  greatly  increased  vascular  tension,  which  is  present  early  in  the 
course  of  the  nephritis,  is  associated  with  more  or  less  marked  slowing 
of  the  pulse.  Clinically,  it  may  be  possible  to  make  out  this  enlarge- 
ment of  the  heart  only  in  the  severe  cases,  necessarily  characterized  by 
extremely  high  blood-pressure. 

Pericarditis  as  a  sequela  of  simple  scarlatina,  though  less  frequent 
than  in  those  cases  complicated  by  involvement  of  the  joints,  by  sepsis 
or  by  nephritis,  occurs  occasionally,  and  may  be  associated  with  serous, 
or — rarely — purulent,  exudate  into  the  pericardium;  and  in  such 
instances  may  readily  lead  to  confusion  in  differentiating  between 
simple  dilatation  with  hypertrophy  and  the  presence  of  fluid.  Endo- 
carditis is  more  often  seen  following  nephritis  than  in  simple  scar- 
latina, though  it  is  probable  that,  in  many  instances,  murmurs  depend- 
ent upon  a  myocardial  change  are  assumed  to  be  of  a  true  endocardial 
origin.  With  the  occurrence  of  a  septic  infection,  and  the  presence  of 
pus-cocci  as  an  added  factor,  the  danger  and  frequency  of  subsequent 
involvement  of  the  heart  is  greatly  increased,  any  condition  from  a 
simple  endocarditis  to  a  general  pancarditis  being  possible,  while,  in 
cases  characterized  by  inflammation  of  the  joints,  both  pericarditis  and 
endocarditis  may  occur,  the  latter  being,  under  these  conditions,  a  very 
frequent  complication,  developing,  according  to  Hodger,326  in  32  per 
cent,  of  all  cases. 

Lungs.  —  Apart  from  the  involvement  of  the  upper  respira- 
tory tract,  noted  above  (see  "Throat"),  and  the  occurrence  of  oedema 
of  the  larynx  as  a  sequela  to  an  intercurrent  nephritis,  there  may 
develop  early  in  the  course  of  scarlatina,  during  the  first  or  second 
week,  a  mild  bronchitis,  or  even  a  more  or  less  extensive  broncho- pneu- 
monia, which,  not  infrequently  being  masked  by  the  other  symptoms 
present,  escapes  notice.  Henoch  (loc.  cit.,  p.  680)  holds  that  this  early 
involvement  of  the  bronchi  and  lungs  is  very  much  more  common  than 
we  are  led  to  believe. 


329  Hodger:  See  Eichhorst  (loc.  cit.,  p.  241). 


SCARLATINA.  209 

Later  on,  and  particularly  in  those  cases  with  marked  involvement 
of  the  pharynx,  bronchitis  and  broncho-pneumonia  may  develop  as  a 
result  of  direct  extension  of  the  process  in  the  throat  downward. 
Broncho-pneumonia  may  ensue  from  the  accidental  carriage  of  septic 
material  from  the  throat  into  the  trachea,  bronchi,  and  lungs  (the  so- 
called  Schluck-pneumonie),  or,  again,  it  may  be  the  result  of  direct  in- 
fection through  the  blood-vessels  (a  part  of  the  general  sepsis). 

True  acute  croupous  pneumonia  occurs  more  frequently  in  cases 
complicated  by  scarlatinal  nephritis  than  in  those  which  run  a  normal 
course,  while  the  possibility  of  acute  cedema  of  the  lungs  must  be  re- 
membered. In  McCollom's  series  of  ninety-eight  fatal  cases  (loc.  cit.) 
fifteen  were  due  to  a  broncho-pneumonia. 

Pleurce. — As  already  noted  in  a  certain  number  of  instances,  the 
scarlatinal  virus  shows  a  peculiar  selective  affinity  for  the  serous  mem- 
branes of  the  body,  and  may  even  in  uncomplicated  cases,  cause  inflam- 
mation of  the  pleura,  associated  either  with  or  without  exudation, 
which,  however,  when  present,  almost  constantly  becomes  purulent  as 
a  result  of  a  secondary  infection.  As  a  rule,  in  simple  scarlet  fever 
this  involvement  of  the  pleura  is  first  seen  during  the  second  week  of 
the  attack,  and  is  commonly  unilateral.  More  rarely,  during  convales- 
cence, and  in  cases  unassociated  with  involvement  of  the  joints  or 
other  complications,  a  serous  pleurisy  may  develop,  with  excessive  exu- 
dation, which  not  infrequently  ends  fatally. 

Central  Nervous  System. — Thomas  (loc.  cit.,  p.  275)  considers  the 
occurrence  of  severe  cerebral  or  spinal  symptoms  the  most  frequent 
complication  of  scarlatina.  They  develop,  as  this  writer  says:  "when- 
ever the  disease  runs  a  severe  course,  or  there  are  present  other 
serious  complications."  If  we  consider  the  appearance  of  marked 
cerebral  or  spinal  disturbance  in  every  instance  as  a  true  compli- 
cation of  the  disease  rather  than  as  a  symptom  of  the  infection, 
this  view  must  be  accepted  as  correct;  but  the  author  quoted  admits 
that  it  is  not  always  possible  in  these  cases  to  discriminate  between  a 
symptom  as  such  and  an  actual  complication.  In  almost  all  severe 
cases  the  early  cerebral  symptoms  are  marked,  severe  headache,  fol- 
lowed by  great  languor,  dullness,  or  apathy  being  present,  or,  again, 
convulsions  occurring  but  once,  or  repeated  with  varying  intensity, 
marking  the  onset.  Delirium  of  a  mild  type — in  which  the  patient, 
though  answering  all  questions  rationally,  is  confused,  and  the  familiar 
objects  about  him  become  distorted — may  occur  before  the  appearance 
of  the  eruption,  while  in  other  cases  delirium  with  great  restlessness  is 


210  THE   ACUTE    EXANTHEMATA. 

seen  early  and  persists  throughout  the  course  of  the  febrile  stage,  as- 
suming all  the  seriousness  of  an  added  complication.  In  rare  cases 
the  early  delirium  is  followed  by  rapidly  developing  coma. 

Pronounced  cerebral  symptoms  may  arise  at  any  time  during  the 
course  of  the  disease,  though,  when  occurring  early,  before  the  appear- 
ance of  other  complications,  they  are  largely  due  to  the  intense  tox- 
aemia, and,  in  a  measure  also,  to  the  extreme  elevation  of  the  tempera- 
ture. Very  frequently,  with  the  fall  of  the  temperature,  they  disap- 
pear entirely,  giving  way  to  a  quiet  and  natural  sleep,  out  of  which 
the  patient  wakens  quite  himself  again.  In  many  instances  the  ex- 
treme cerebral  disturbance  may  be  due  simply  to  the  prolonged  eleva- 
tion of  the  temperature. 

In  that  group  of  cases  characterized  by  other  serious  complica- 
tions, with  the  added  danger  of  sepsis,  the  symptoms  referable  to  the 
cerebro-spinal  system  may  be  the  result  of  a  direct  extension  of  the 
local  process,  as  from  mastoid  disease,  or  due  to  septic  emboli  with 
resulting  meningitis  (a  rare  occurrence);  while,  with  the  development 
of  urcemia,  the  appearance  of  ocular  symptoms,  such  as  temporary  par- 
tial loss  of  vision  (amaurosis),  due  to  arrested  papillary  reaction,  and 
retinitis,  or  aphasia  and  hemiplegia  are  the  result,  rather  of  the  inter- 
current  nephritis,  than  of  the  specific  scarlatinal  virus,  and  in  those 
cases  which  recover  eventually  disappear. 

The  Eyes. — Though  the  early  catarrhal  inflammation  of  the  eyes, 
so  constant  an  accompaniment  of  measles,  is  absent  in  scarlatina,  and 
local  inflammatory  processes  affecting  them,  as  the  direct  result  of  the 
specific  poison,  are  of  the  rarest  occurrence,  various  complications  may 
arise  during  the  course  of  the  disease,  due  to  co-existent  complications, 
many  of  which  have  been  already  described.  In  every  severe  case,  with 
the  greatly  diminished  secretion  of  the  lacrymal  glands  and  the  slug- 
gish action  of  the  eyelids,  there  is  danger  of  foreign  particles  lodging 
upon  the  cornea,  with  resulting  inflammation,  necrosis,  and  even  pan- 
ophthalmitis. 

Early  in  the  attack  photophobia  or  a  mild  conjunctivitis  may  arise 
from  direct  extension  of  the  inflammatory  process  accompanying  the 
eruption  in  the  immediate  neighborhood  of  the  eyes,  usually  follow- 
ing abrasions  upon  the  eyelids  themselves. 

The  lacrymal  duct,  and  the  lacrymal  gland  as  well,  may  be  in- 
volved by  an  extension  of  the  local  pharyngeal  inflammation  and 
ulceration.  Catarrhal  conjunctivitis,  rarely  with  diphtheritic  inflam- 
mation, may  occur.  Rarely  the  following  complications  may  arise: 


SCARLATINA.  211 

Keratitis,  simple  or  purulent,  with  occasional  perforation  of  the  cornea; 
iritis,  choroiditis,  and  panophthalmitis;  amblyopia  and  amaurosis; 
neuroretinitis  of  nephritic  origin;  optic  neuritis  with  meningitis,  and 
hcemorrhage  into  the  retina. 

Gastro-intestinal  Tract. — Occasionally,  early  in  the  course  of  the 
disease,  particularly  in  young  children,  a  more  or  less  severe  stomatitis 
occurs,  with  ulceration  of  the  mucous  membrane  of  the  mouth  and 
cheeks,  accompanied  by  increased  salivation  or  even  hasmorrhages: 
frequently  a  very  painful  condition,  and  one  which  seriously  interferes 
with  nutrition.  More  rarely,  actual  gangrene,  or  noma,  results,  with 
rapid  destruction  of  the  tissues  of  the  cheek  or  tongue. 

The  early  initial  vomiting,  so  constant  an  accompaniment  of  the 
onset  of  the  disease,  is  essentially  a  symptom  of  the  infection  associated 
with  the  sudden  rise  of  temperature  and  the  invasion  of  the  system 
by  the  specific  virus.  It  is  frequently  seen  later  in  the  course  of  the 
attack,  associated  with  the  development  of  nephritis,  or  with  the  onset 
of  uraemia,  and,  clinically,  it  is  impossible  to  distinguish  the  vomiting 
due  to  reflex  disturbance  as  a  result  of  the  disease  itself,  of  nephritis, 
of  uraemia,  or  as  following  an  aggravated  cough,  from  that  due  to  any 
one  of  the  rare  pathological  lesions  which  are  found  occasionally  post- 
mortem. 

On  the  part  of  the  intestinal  tract  a  severe  diarrhoea  is  frequently 
an  early  and  prominent  symptom,  acquiring,  in  some  instances,  such 
an  extreme  grade  as  to  constitute  an  actual  complication.  Litten327 
has  classified  the  inflammations  of  the  intestinal  tract  in  scarlatina  into 
three  groups: — 

(A)  Simple  catarrhal  enteritis.     Usually  of  mild  character  and 
short  duration. 

(B)  Dysentery,  with  tenesmus  and  bloody,  purulent  stools. 

(C)  The  diarrhoeas  of  typhoidal  character,  with  loose,  watery  move- 
ments, associated  with  marked  tympanites,  and  with  great  liability  to 
fatal  haemorrhages,  and  characterized  by  markedly  typhoidal  symp- 
toms. 

Liver. — Enlargement  of  the  liver  sometimes  occurs,  usually  most 
marked  at  the  time  of  greatest  intensity  of  the  eruption.  It  may  or 
may  not  be  readily  palpable.  In  severe  cases  there  may  be  an  actual 
atrophy. 

The  presence  of  a  mild  degree  of  icterus  during  scarlet  fever 


627  Litten:  "Charit6  Annalen,"  vol.  vli,  pp.  128  et  seq. 


212  THE    ACUTE    EXAXTHEMATA. 

is  comparatively  frequent,  many  epidemics  being  peculiarly  character- 
ized by  the  commonness  of  its  occurrence.  It  is  usually  of  mild  grade, 
and  is  more  pronounced  after  the  disappearance  of  the  eruption,  com- 
monly passing  away  with  the  establishment  of  convalescence.  Fatal 
cases  are,  however,  recorded  in  literature,  often  associated  with  acute 
destructive  changes  in  the  liver.  According  to  Baginsky,328  its  de- 
velopment, coincident  with  or  during  the  existence  of  a  nephritis,  is 
particularly  to  be  dreaded,  as  predisposing  to  the  danger  of  uremia. 

Skin. — In  addition  to  those  irregular  forms  of  scarlatina,  so  called 
from  the  peculiarity  of  the  eruption,  there  are  seen  in  a  certain  num- 
ber of  cases  other  changes,  either  local  or  general,  which,  differing 
from  the  normal,  are  essentially  complications.  The  occurrence  of 
these  conditions,  which  are  commonly  the  result  of  a  localized  or  gen- 
eral septic  infection,  due  to  the  entrance  of  pus-cocci  into  the  deeper 
layers  of  the  skin,  is  very  variable.  In  a  few  rare  cases  the  process  of 
desquamation  is  extreme,  involving  the  deeper  layers  of  the  dermis  to 
such  an  extent  that  raw  and  excoriated  surfaces  follow.  Exception- 
ally the  nails  may  be  lost.  In  severe  cases  the  development  of  a 
decubitus  over  those  areas  exposed  to  constant  pressure  is  not  uncom- 
mon. Less  frequently  a  general  furunculosis  or  multiple  abscesses  are 
seen,  while  rarely  gangrene  may  ensue,  involving  the  skin,  either 
locally,  or  attacking  an  extremity,  or  even  the  genitalia.  Among 
other  possible  conditions  the  occurrence  of  erysipelas;  eczema  affect- 
ing the  face,  ears,  and  head;  urticarial  and  pemphigoid  eruptions  has 
been  noted. 

Phlebitis. — Moizard  and  Ulmann329  have  recently  described  the 
very  rare  development  of  phlebitis,  occurring  during  the  course  of 
scarlet  fever,  in  a  case  under  their  observation,  affecting  the  right 
axillary  and  humeral  veins;  and  have  collected  from  the  literature 
notes  of  four  cases  in  which  phlebitis  developed  during  scarlatina. 

A  bacteriological  examination  in  this  instance  proved  the  phle- 
bitis to  be  the  result  of  a  streptococcic  septicasmia.  In  the  four 
cases  cited  by  them  a  branch  of  the  right  brachio-cephalic,  the  inferior 
vena  cava,  the  jugular,  the  veins  of  Galen,  and  the  right  lateral  sinus 
were  involved.  In  conclusion,  they  were  not  able  to  establish  any 
absolute  relationship  between  the  severity  of  the  infection  and  the 


328  Baginsky  (Adolf):  "Die  Kinderkrankheiten"   (Berlin,  1889),  p.  117. 
S2>  Moizard  and  Ulmann:  "La  Phlebite  Scarlatineuse."    Archives  de  Med.  des  En- 
fants,  vol.  li,  No.  10,  1899,  p.  601. 


SCAKLATINA.  213 

occurrence  of  phlebitis,  though,  judging  from  the  cases  reported,  it 
would  appear  to  he  more  common  in  the  grave  infections.  It  may 
take  place  at  any  time  between  the  fourth  and  the  fifteenth  day. 

SEQUELAE. 

Considering  under  this  head  those  conditions  which  remain  as  a 
temporary  or  permanent  result  of  the  scarlatinal  process,  it  is  not  sur- 
prising that,  in  a  disease  which  manifests  itself  with  such  varying 
degrees  of  intensity,  affecting,  in  the  severer  forms,  almost  every  organ 
in  the  body,  we  may  find  each  individual  complication  giving  rise,  not 
infrequently,  to  sequelae  of  greater  or  less  severity. 

As  the  complications  of  scarlatina  are  often  but  the  exaggeration 
of  single  symptoms,  so,  naturally,  in  many  cases,  the  sequelae  are  but 
the  result  of  aggravated  complications.  It  is  an  interesting  fact  that 
in  many  instances  after  recovery  from  an  unusually  severe  scarlatinal 
toxemia,  which  have  been  unaccompanied  by  complications,  there  is  a 
marked  insusceptibility  on  the  part  of  the  individual  to  other  infectious 
diseases.  Exceptions,  of  course,  occur  here  as  elsewhere. 

In  a  certain  number  of  cases  recovery  may  be  followed  by  ancemia, 
more  or  less  persistent,  and  associated  with  a  slightly  delayed  return 
of  the  physical  strength,  and  some  susceptibility  to  mild  affections; 
rarely  recovery  is  followed  by  marked  cachexia.  There  is  a  striking 
contrast  between  measles  and  scarlet  fever  in  respect  of  the  absence 
of  any  marked  predisposition  to  tuberculosis  in  the  latter  disease,  fol- 
lowing which  a  latent  tubercular  infection  is  not  frequently  seen.  In 
a  small  percentage  of  cases  there  may  develop  evidences  of  a  tubercular 
process  in  the  lungs  and  lymph-glands,  occasionally  in  the  bones  or 
joints,  and  in  rare  instances  in  the  meninges. 

Among  the  specific  sequels  of  scarlet  fever  dependent  upon  in- 
dividual complications  may  be  included  those  conditions  resulting 
from  excessive  involvement  of  the  pharynx,  associated  with  strep- 
tococcic  infection,  or  complicated  by  true  diphtheria.  Following 
the  severe  septic  anginas,  with  extensive  inflammation  or  ulcera- 
tion,  there  may  remain  a  chronic  enlargement  of  the  tonsils,  or  chronic 
inflammatory  changes  in  the  pliaryngeal  and  nasal  mucous  membrane. 
Forchheimer330  has  seen  persistent  ozcena  as  a  sequela  of  a  streptococcic 
angina  in  scarlet  fever.  Following  a  true  diphtheritic  infection  in 


330  Forchheimer  (F.):  "Scarlet  Fever,"  in  "Twentieth  Century  Practice  of  Med- 
icine" (New  York,  1898),  vol.  xiv,  p.  80. 


214  THE    ACUTE    EXANTHEMATA. 

scarlatina,  one  may  meet  with  paralyses  involving  the  muscles  of  ac- 
commodation or  affecting  the  soft  palate. 

The  occurrence  of  partial  loss  of  hearing,  or  of  total  deaf  ness, 'as 
a  result  of  otitis  media,  is  of  the  gravest  importance,  and,  unhappily, 
one  of  the  commonest  sequela?  of  the  disease.  Chronic  suppuration 
of  the  middle  ear,  caries  and  necrosis  of  the  bony  structure  of  the 
tympanum,  involvement  of  the  mastoid  cells,  paralysis  of  the  facial 
-nerve,  and,  rarely,  involvement  of  the  meninges  or  brain  may  be  the 
result  of  a  suppurative  otitis  media. 

As  the  result  of  an  intercurrent  acute  scarlatinal  nephritis,  the 
possibility  of  a  subacute  or  chronic  nephritis  must  not  be  lost  sight  of, 
though  the  occurrence  of  such  a  chronic  nephritis  is  not  common. 
While  the  average  duration  of  an  ordinary  scarlatinal  nephritis  may  be 
said  to  extend  from  four  to  six  weeks,  albumin  and  casts  have  been 
present  in  the  urine  and  cedema  of  the  face  has  been  noted  in  the 
tenth  week  of  the  nephritis. 

Endocarditis,  with  resulting  permanent  lesion  of  the  valve-seg- 
ments, is  a  not  uncommon  sequela  of  scarlatina,  affecting  usually  the 
mitral  leaflets. 

In  rare  cases,  as  a  result  of  the  scarlatinal  synovitis  or  arthritis, 
there  may  remain  permanent  deformity  and  stiffness  of  one  or  more 
of  the  articulations  attacked,  the  large  joints,  as  a  rule,  being  affected, 
following  a  pycemia. 

Among  the  sequela?  depending  upon  changes  in  the  skin  the  fol- 
lowing are  occasionally  seen:  Torticollis,  the  result  of  cellulitis,  and 
rarely  as  a  sequela  to  inflammation  of  the  cervical  vertebra?;  chronic 
furunculosis;  intercurrent  chronic  skin  eruptions,  greatly  delayed; 
and  even  secondary  desquamation. 

Among  the  conditions  which  may  remain  as  a  result  of  the  in- 
volvement of  the  central  nervous  system  Fiirbringer331  has  noted  the 
occurrence  of  a  localized  hcemorrhagic  encephalitis,  and  Henoch  has 
seen  aphasia  of  almost  a  year's  duration.  Moore332  notes  the  develop- 
ment of  chorea  at  periods  varying  from  two  to  six  months  after  the 
attack.  Priestly333  cites  13  cases  of  chorea  following  scarlatina,  out 
of  5355  cases  under  observation:  a  proportion  of  1  in  412.  Carslaw334 


881  Fiirbringer  (P.):  "Scarlatina,"  in  Eulenberg's  "Real-Encyclopadie,"  vol.  xvil, 
1889,  p.  478. 

333  Moore  (J.  W.):  "Eruptive  and  Continued  Fevers"  (New  York,  1892),  p.  171. 

883  Priestly  (J.):  Brit.  Med.  Jour.,  September,  1897,  p.  805. 

384  Carslaw:  See  Osier,  on  "Chorea  and  Choreiform  Affections"  (Philadelphia,  1894), 
p.  17. 


SCARLATINA.  215 

gives  3  cases  out  of  533,  while  scarlet  fever  is  given  as  the  sole  ante- 
cedent cause  of  chorea  in  6  per  cent,  of  all  cases  in  the  Collective 
Investigation  Committee's  Eeport.335 

Acute  psychosis  may  develop  during  convalescence.  Chronic 
oedema  of  the  glottis  or  a  gradual  paralysis  of  the  vocal  cords,  though 
rare,  has  been  reported.  Further  rare  conditions  noted  in  the  litera- 
ture are  choreifom-athetotic  movements  of  a  spastic  arm,  chronic  epi- 
leptiform  conditions,  tetany,  and  traumatic  tetanus  following  surgical 
scarlatina.336 

PATHOLOGY. 

The  gross  and  histological  lesions  found  post-mortem  in  scarlet 
fever  depend  essentially  upon  two  processes:  first,  the  action  of  the 
scarlatinal  toxin,  associated  with  the  changes  seen  in  any  acute  febrile 
disease;  and,  secondly,  they  may  occur  as  a  result  of  a  mixed  infection, 
due  to  entrance  into  the  organism  of  the  streptococcus  pyogenes,  the 
staphylococcus  pyogenes  aureus  or  albus,  the  pneumococcus,  and,  rarely, 
other  micro-organisms.  So  long  as  the  specific  agent  concerned  in  the 
scarlatinal  infection  remains  obscure,  it  must  be  impossible — in  many 
instances,  at  least — to  determine,  in  a  given  case,  which  of  these  two 
elements  is  the  predominant  one.  In  cases  succumbing  early  in  their 
course  to  the  intensity  of  the  poison,  before  the  development  of  sec- 
ondary infections,  we  must  assume  the  changes  present  to  be  due  to 
the  specific  scarlatinal  virus,  while  in  those  which  prove  fatal  later, 
associated  with  grave  throat  lesions,  streptococcic  angina,  etc.,  the  pos- 
sibility of  an  added  etiological  element  in  the  lesions  present  after 
death  must  be  admitted. 

Skin  Eruption. — The  scarlatinal  exanthem  so  peculiarly  charac- 
teristic of  the  disease  is  not  seen  after  death,  except  in  cases  in  which 
the  inflammatory  process  has  been  unusually  intense,  when  the  skin 
may  still  retain  a  slightly  reddened  appearance;  and  in  the  severe 
hsemorrhagic  forms  in  which  there  has  been  an  actual  exudation  of 
the  coloring  matter  of  the  blood,  with  the  formation  of  definite 
petechiae. 

The  process  consists  essentially  in  a  hyperaemia,  followed  later  by 
the  establishment  of  desquamation,  by  an  exudation  into  the  rete 
Malpighii,  and  by  cell-proliferation.  Unna,337  however,  does  not  re- 


335  See  Brit.   Med.  Jour.,  vol.   i,  1887,  p.   425. 

336  See  Fiirbringer  (loc.  cit.,  p.  478). 

837  Unna  (P.  G.):  See  Orth's  "Lehrbuch  der  Spec.  Path.  Anatom."  (eighth  edition, 
1894),  vol.  ii,  pp.  629  et  seq. 


216  THE    ACUTE    EXANTHEMATA. 

gard  the  process  as  in  any  sense  an  inflammatory  one.  According  to 
this  authority,  the  following  changes  occur  with  the  development  of 
the  exanthem :  There  is  present  at  the  height  of  the  eruption  a  marked 
shrinking  of  the  epidermis,  while  the  blood-vessels  of  the  cutis  and 
papillae  are  widely  dilated,  to  which  fact  he  attributes  the  turgescence 
of  the  skin,  so  often  seen  at  this  stage,  rather  than  to  the  presence  of 
actual  oedema.  There  is  further,  according  to  Unna,  a  striking  ab- 
sence of  any  true  inflammatory  exudation  of  white  blood-corpuscles. 
Toward  the  end  of  the  eruptive  stage,  and  with  beginning  desquama- 
tion,  collections  of  connective  tissue  cells  are  usually  seen  about  the 
vessels  of  the  papillae.  Plasma-cells  are  not  formed,  while  mast-cells 
in  any  large  number  are  first  seen  with  the  establishment  of  desquama- 
tion.  The  rete  Malpighii  shows  no  marked  early  changes,  mitosis  oc- 
curring first  during  desquamation.  He  considers  the  development  of 
oedema  a  co-existent  condition  of  neurotoxic  origin,  and  not  due  to  the 
erythema,  regarding  the  entire  process  as  a  vasomotor  disturbance,  and 
not  a  true  inflammation. 

Von  Jiirgensen  (loc.  cit.,  pp.  114  et  seq.)  agrees  with  the  view  held 
by  Unna,  considering  the  occurrence  of  a  true  interstitial  cedema  of 
the  cutis  in  scarlatina  the  exception;  and  further  holds  that  it  is  im- 
possible to  speak  of  the  process  as  an  inflammatory  one,  assigning  the 
alterations  in  the  skin  to  the  effect  of  the  specific  scarlatinal  virus, 
which  produces  a  pure  vasomotor  paralysis  of  the  peripheral  vessels. 
Thomas  (loc.  cit.,  pp.  202  et  seq.)  considers  the  changes  due  to  a  hyper- 
aemia  and  exudation  into  the  rete  Malpighii.  Ziegler338  describes  the 
scarlatinal  exanthem  under  the  head  of  "inflammations  of  the  skin," 
as  being  characterized  by  a  more  or  less  extensive  cellular  exudate  into 
the  tissues. 

Kaposi339  holds  that  the  anatomical  changes  in  the  skin  in  the 
normal  forms  are  due  to  hyperaemia  with  moderate  exudate,  the  papil- 
lary and  vesicular  eruptions  arising  as  a  result  of  excessive  exudation 
and  cell-proliferation  in  the  papilla?  and  rete.  Pearce,340  who,  in  a 
study  of  twenty-three  fatal  cases  of  scarlatina,  has  added  a  most  valu- 
able contribution  to  our  knowledge  of  the  pathology  of  the  disease, 
records  the  histological  lesions  in  the  skin  in  nine  cases.  Briefly  they 
are  as  follow:  Early  dilatation  and  congestion  of  the  blood-vessels, 


188  Ziegler  (E.):  "Lehrbuch  der  Spec.  Path.  Anatom."  (Jena,  1895),  vol.  li,  p.  416. 
888  Kaposi   (M.):   "Path,  und  Therapie  der  Hautkrankheiten"   (Berlin  and  Vienna, 
1899),  p.  243. 

840  Pearce  (R.  M.):  "Boston  City  Hospital  Reports,"  X  Series,  1899,  p.  50. 


SCARLATINA.  217 

and  slight  dilatation  of  the  lymphatics,  together  with  the  occasional 
presence  of  a  few  leucocytes  and  lymphoid  cells  about  the  lymphatic 
vessels  beneath  the  rete;  later,  from  the  fifth  to  the  tenth  day  a 
marked  infiltration  of  the  epithelium  with  polymorphonuclear  leuco- 
cytes, which  were  even  found  mixed  with  the  desquamating  epithelial 
cells,  and,  in  many  instances,  with  red  blood-corpuscles  as  well.  The 
deeper  cells  showed  occasional  mitosis. 

It  will  be  seen  that  this  description  differs  materially  from  that 
given  by  Unna  in  the  marked  infiltration  and  exudation  of  white  blood- 
corpuscles,  as  a  result  of  which  it  is  evident  that  the  process  may  be 
inflammatory,  as  well  as  of  vasomotor  origin.  The  minute  bright-red 
points  in  the  exanthem  of  scarlatina  represent  small  focal  areas  of  in- 
tense dilatation  and  congestion,  and,  though  commonly  most  marked 
about  the  hair  follicles,  the  rash  bears  no  definite  relation  to  them,  and 
may  develop  equally  well  over  a  cicatrix  following  a  burn.341 

Desquamatian. — Following  the  disappearance  of  the  exanthem  the 
superficial  layers  of  the  epidermis  are  lost,  desquamation  being  estab- 
lished early,  as  a  rule,  over  those  areas  where  the  eruption  was  first 
seen.  As  already  noted,  it  is  most  extensive  where  this  process  has 
been  intense,  occurring  as  a  direct  result  of  trophic  changes  in  the  cells 
of  the  epidermis,  induced  by  the  action  of  the  specific  poison  and  the 
local  inflammatory  reaction.  Earely  these  changes  may  involve  other 
allied  structures  as  well.  The  nails  of  the  fingers  and  toes  may  drop 
off,  or  the  hair  may  fall  out,  or  even  warts  may  drop  off  as  a  conse- 
quence of  scarlet  fever.342 

According  to  Unna,  every  alteration  occurring  in  the  skin  in  the 
course  of  the  disease  is  the  result  of  the  direct  action  of  the  specific 
scarlatinal  virus. 

Mucous  Membranes  of  the  Pharynx  and  Nose. — The  changes  here 
are  essentially  those  seen  in  the  skin — dilatation  and  congestion  of  the 
blood-vessels  and  lymphatics,  with,  later,  a  leucocytic  infiltration. 

Tongue. — In  eight  cases  examined  by  Pearce  (loc.  cit.)  the  process 
in  the  tongue  was  found  to  be  similar  to  that  in  the  skin,  but  begin- 
ning earlier  and  being  very  much  more  pronounced,  with  marked  in- 
volvement of  the  papillae:  two  points  which  agree  with  clinical  ex- 
perience. 

Lymphatic  System. — The  only  really  constant  gross  lesion  in  scar- 
latina is  an  hyperplasia  affecting  all  the  lymphoid  structures  of  the 

841  See  Thomas  (loc.  cit.,  p.  212). 
342  See  Moore  (loc.  cit.,  p.  173). 


218  THE   ACUTE    EXANTHEMATA. 

body.  Clinically,  this  is  seen  in  the  enlargement  of  all  the  superficial 
lymphatic  glands,  most  marked,  as  already  noted,  in  the  maxillary  and 
submaxillary  glands,  which  not  infrequently  undergo  suppuration  and 
break  down;  and  in  the  enlargement  of  the  spleen,  which  occasion- 
ally acquires  an  extreme  size.  After  death  in  addition  a  pronounced 
hyperplasia  of  all  the  lymphoid  elements  of  the  tissues,  including  the 
single  and  agminated  glands  of  the  intestinal  tract,  is  usually  found. 
Histologically  the  lesions  have  been  described  by  Klein343  and  by 
Pearce  (loc.  cit.).  According  to  the  latter  observer,  the  changes  are 
not  constant  in  all  cases.  In  the  lymph-nodes  there  is  congestion  of  the 
blood-vessels,  together  with  dilatation  of  the  lymph-sinuses,  which 
contain  large  endothelial  cells.  These  latter  are  frequently  phagocytic, 
containing  lymphoid  cells,  red  blood-corpuscles,  and,  less  commonly, 
polymorphonuclear  leucocytes.  The  lymph-nodules  are  enlarged,  with 
pale  centres,  due  to  the  presence  of  large  numbers  of  endothelial  cells. 

Spleen. — The  spleen  may  be  normal  in  size  or  greatly  enlarged. 
The  histological  changes  consist  essentially  in  an  hyperplasia  of  the 
splenic  pulp  together  with  infiltration  of  plasma-cells,  enlargement  of 
the  Malpighian  bodies,  and  congestion  of  the  blood-vessels.  Focal 
lesions,  either  inflammatory  or  haemorrhagic,  may  be  present. 

Heart. — The  pathological  changes  found  in  the  heart  following 
scarlet  fever  may  arise  as  a  result  of  the  scarlatinal  toxin  alone,  or  may 
be  due  to  the  occurrence  of  a  mixed  infection  with  the  presence  of 
streptococci  or  staphylococci  in  the  circulating  blood.  Clinically,  the 
early  evidence  of  the  action  of  the  scarlatinal  virus  upon  the  heart  is 
seen  in  the  occurrence  of  acute  dilatation,  which  not  infrequently  de- 
velops with  unusual  rapidity,  being  associated  with  certain  transitory 
murmurs,  while,  in  case  of  nephritis,  it  has  been  shown  that  the  danger 
of  subsequent  anatomical  change  in  the  heart  is  markedly  increased. 
Steffen344  considers  the  oncome  of  acute  dilatation  under  these  circum- 
stances of  the  gravest  significance.  It  may,  according  to  this  observer, 
take  place  so  rapidly  that  the  apex-beat  is  found  in  the  anterior  axil- 
lary line  within  twenty-four  to  forty-eight  hours.  As  a  natural  result, 
dilatation  of  the  left  side  of  the  heart  follows,  while  the  right  side 
may  also  be  involved  in  a  slight  degree.  It  has  further  been  shown  by 
Silberman345  that,  following  this  dilatation,  an  acute  hypertrophy  of 


943  Klein  (E.):   "Trans.  Path.   Society"   (London,  1877). 

'"Steffen    (A.):    "Ueber    einige    Wichtige    Krankheiten    des    Kindlichen    Alters' 
(Tubingen,  1895),  p.  211. 

848  Silberman  (O.):  "Jahrb.  f.  Kinderh.,"  vol.  xvii,  p.  178. 


SCARLATINA.  219 

the  left  ventricle  may  ensue,  while  Romberg  (loc.  cit.)  has  demon- 
strated the  occurrence  of  an  acute  myocarditis  involving  not  only  the 
muscle-fibres  of  the  heart,  but  the  interstitial  tissue  also:  a  fact  of 
great  clinical,  as  well  as  pathological,  significance. 

Pericarditis  may  be  present  as  a  result  of  the  direct  extension  of 
the  inflammatory  process  from  the  inner  layer  of  the  pericardial  sac, 
when  not  infrequently,  as  shown  by  Romberg,  there  is  but  slight  gross 
evidence  of  inflammatory  change.  Otherwise  it  may  follow  primary 
involvement  of  the  pericardium,  which  shares  in  the  susceptibility  of 
the  serous  membranes.  Occasionally  exudation  occurs  in  the  simple 
forms.  When  due  to  the  existence  of  a  mixed  infection  of  streptococcic 
or  staphylococcic  origin,  it  is  frequently  associated  with  more  or  less 
exudation  of  serum  and  fibrin  formation.  Less  commonly  the  exuda- 
tion of  fluid  into  the  pericardial  sac  reaches  an  extreme  degree.  Puru- 
lent and  hsemorrhagic  effusions  are  rare. 

Endocarditis  is  a  not  uncommon  result  of  the  scarlatinal  infec- 
tion, the  inflammatory  process  attacking  the  endocardial  lining  of  the 
cavity  of  the  heart,  leaving  the  valves  free;  or  it  may  involve  the 
valvular  segments,  giving  rise  to  a  simple  thickening  at  the  site  of  the 
lesion,  usually  situated  at  the  margin  of  the  valves.  .  Less  frequently  a 
true  endocarditis  verrucosa  may  follow  the  simple  process.  Although 
it  is  possible  that  endocarditis  may  occur  as  a  result  of  the  scarlatinal 
toxin,  as  seems  to  have  been  true  in  the  cases  studied  by  Romberg,  it 
is  far  more  frequently  due  to  the  existence  of  a  mixed  infection,  fol- 
lowing the  direct  action  of  the  micro-organisms  circulating  in  the 
blood,  or  even  of  the  toxins  elaborated  by  them.  In  many  instances 
a  true  pancarditis  may  be  present,  the  endocardium,  myocardium,  and 
pericardium  as  well  being  more  or  less  involved  in  the  inflammatory 
process. 

Kidneys. — The  subject  of  the  pathological  lesions  of  the  kidney 
following  scarlet  fever  has  been  involved  in  much  discussion.  Many 
observers  have  asserted  that  the  changes  resulting  from  the  scarlatinal 
poison  are  confined  essentially  to  the  parenchyma;  others  have  found 
changes  in  the  interstitial  tissue  alone;  and  still  a  third  group  have  de- 
scribed mixed  forms  of  nephritis.346 

Friedlander  (loc.  cit.),  writing  in  1883,  said:  "Whoever  attempts 
to  glean  from  the  voluminous  literature  of  the  subject  the  various 
alterations  which  mav  occur  in  the  kidnev  as  a  result  of  the  scarlatinal 


349  For  critical  summary  of  literature  see  Pearce  (loc.  cit.). 


220  THE    ACUTE    EXANTHEMATA. 

process  soon  learns  that  it  is  extremely  difficult  to  find  one's  way,  in 
the  confusion  of  assertions  and  theories  which  often  contradict  each 
other." 

By  many  writers  that  form  of  nephritis  peculiarly  characteristic 
of  the  scarlatinal  kidney  is  still  described  as  essentially  glomerular. 
Klebs,347  in  1876,  described  the  frequent  occurrence  of  an  acute  inter- 
stitial nephritis  early  in  the  course  of  the  disease,  and  first  called  at- 
tention to  the  existence  of  a  glomerular  nephritis  which  developed  dur- 
ing convalescence.  Klein,  in  1877  (loc.  cit.,  p.  430),  found  definite 
glomerular  nephritis  in  23  cases  of  scarlet  fever,  which  were  fatal  at 
periods  ranging  from  the  second  day  to  the  seventh  week.  Wagner,348 
in  1880,  said  he  had  not  seen  a  pure  glomerular  nephritis  following 
scarlatina.  Friedlander,  in  1883  (loc.  cit.),  as  a  result  of  229  necropsies 
in  fatal  cases  of  scarlet  fever,  classified  the  pathological  lesions  of  the 
kidneys  as  follows: — 

1.  Initial  Catarrlial  Nephritis  (the  Early  Form  occurring  Coin- 
cidently  with  or  Immediately  following  the  Eruption*). — Anatomically 
the  kidneys  are  moderately  hyperaemic,  the  glomeruli  appearing  as 
small,  red  points.    There  is  usually  no  marked  cloudiness  of  the  cortical 
substance.     Histologically,  cloudy  swelling  of  the  tubular  epithelium 
is  seen,  while  the  glomerular  tufts  are  normal.    The  capsular  epithe- 
lium is  slightly  thickened.    Occasionally  a  small  amount  of  albuminous 
exudate  between  the  capsule  and  glomerulus  is  present. 

2.  The  Large,  Pale,  H&morrhagic  Kidney  (Interstitial  Nephritis; 
Septic  Nephritis). — This  condition  may  develop  in  the  first,  as  well  as 
in  the  third  and  fourth,  week  of  the  attack.    According  to  this  ob- 
server, it  is  rare,  occurring  in  but  12  of  his  cases.     The  kidneys  are 
large  and  pale,  with  grayish-red  cortex.    The  glomeruli  are  commonly 
not  visible.    Usually  large  numbers  of  small,  punctate  haemorrhages  are 
present.    Histologically  there  is  a  marked  infiltration  of  the  interstitial 
tissue,  with  small,  round  cells.    Commonly  but  slight  alteration  of  the 
epithelial  cells  is  noted.    This  form  is  found  usually  in  association  with 
severe  diphtheritic  affections  of  the  throat,  phlegmon  of  the  neck,  etc., 
and  also  in  severe  septic  scarlatinal  nephritis  with  small  foci  of  bac- 
teria in  the  tissues  of  the  kidney. 

3.  The  Glomerulonephritis  (Post-scarlatinal  Nephritis).  —  This  is 
considered  by  Friedlander  the  most  important  and  typical  form,  and 


847  Klebs  (E.):  "Handbuch  Path.  Anatom."   (Berlin,  1876),  vol.  i,  p.  632. 

348  Wagner  (E.):  Deutsche  Archiv  f.  klin.  Med.,  1880,  vol.  xxv,  pp.  529  et  seq. 


SCARLATINA.  221 

as  almost  characteristic  of  scarlatina.  It  occurred  in  42  cases  of  his 
series,  death  being  due,  in  the  majority  of  these,  to  a  pure  glomerular 
nephritis  alone.  Anatomically,  the  kidneys  are  hyperaemic,  their  con- 
sistency is  increased,  and  the  glomeruli  appear  as  small,  grayish  points, 
slightly  larger  than  normal.  Histologically,  the  changes  are  confined 
to  the  glomeruli,  which  contain  little  or  no  blood;  they  are  enlarged 
and  show  a.  marked  increase  of  nuclei.  The  glomerular  loops  are  con- 
verted into  a  solid  mass,  and  the  capsular  epithelium  is  usually  slightly 
thickened.  The  interstitial  tissue  appears  normal. 

Councilman,349  in  a  recent  monograph  upon  acute  and  subacute 
nephritis,  says:  "With  slight  differences  in  the  intensity  of  the  lesions 
due  to  conditions  which  we  do  not  understand,  and  which  may  repre- 
sent increased  or  diminished  local  resistance,  all  susceptible  tissues  will 
be  affected."  He  further  remarks  that,  in  all  serious  lesions  of  the  kid- 
ney, we  find  that  in  one  case  the  glomeruli  are  principally  involved, 
while  in  other  cases,  again,  there  are  lesions  of  the  connective  tissue, 
consisting  of  active  cell-proliferation.  The  glomerular  lesions  may  be 
accompanied  by  degenerative  changes  in  the  tubular  epithelium,  which 
may  be,  in  part  or  wholly,  secondary  to  the  lesions  in  the  glomeruli. 
On  the  other  hand,  hyperplasia  of  the  connective  tissue,  though  often 
accompanied  by  degenerative  changes  in  the  epithelium,  cannot  be  con-' 
sidered  secondary  to  such  changes. 

Based  upon  a  purely  anatomical  classification,  in  which  mixed 
forms  often  occur,  he  describes,  under  the  head  of  acute  diffuse  nephri- 
tis, the  following  forms: — 

1.  Acute  degenerative  nephritis,  occurring  chiefly  in  infectious 
diseases. 

2.  Acute  glomerular  nephritis,  occurring  in  infectious  diseases, 
notably  in  acute  endocarditis,  measles,  and  diphtheria. 

3.  Acute  haemorrhagic  nephritis. 

4.  Acute  interstitial  non-suppurative  nephritis,  occurring  notably 
in  diphtheria  and  scarlet  fever.    Macroscopically,  the  kidney  is  large, 
pale,  and  mottled.     On  section  it  appears  moist  and  opaque,  and  the 
markings  are  obscure.     Histologically,  the  essential  lesion  consists  in 
acute  proliferation  of  the  cells  in  the  intertubular  tissue,  the  prolifera- 
tion taking  place  chiefly  from  the  vascular  endothelium.    The  cells  lie 
within  and  without  the  vessels,  and  are  present  chiefly  in  the  inter- 
mediate zone  of  the  kidney  between  the  pyramids  and  cortex.    There 


349  Councilman  (W.  T.):  Boston  City  Hospital  Reports,  VIII  Series,  1897,  pp.  38  et 
seq. 


222  THE    ACUTE    EXANTHEMATA. 

is  more  or  less  degeneration  and  necrosis  of  the  tubules.  Leucocytes 
in  small  numbers  may  be  present.  The  glomeruli  are  not  affected. 

Three  such  cases  (Nos.  1,  2,  and  6)  of  pure  interstitial  nephritis  fol- 
lowing scarlatina  with  no  glomerular  changes  are  further  described  by 
Councilman  (loc.  cit.},  while  in  one  case  (No.  21),  an  adult  kidney  from 
a  scarlet-fever  patient,  the  glomeruli  were  increased  in  size,  the  capsules 
dilated  and  filled  with  epithelial  cells,  and  the  cells  in  the  glomeruli 
increased  in  number.  There  was  no  increase  of  connective  tissue,  nor 
any  proliferation  of  the  interstitial  cells. 

Out  of  twenty-three  cases  examined  by  Pearce  (loc.  cit.)  he  found 
acute  degenerative  changes  in  all.  In  no  case  were  there  any  glome- 
rular changes,  an  acute  interstitial  nephritis  being  the  important  lesion. 
In  five  cases  it  was  present  in  a  slight  degree,  while  in  four  which  were 
fatal  on  the  eighth,  ninth,  fourteenth,  and  fifteenth  days,  respectively, 
the  interstitial  changes  were  pronounced.  As  a  result  of  these  studies 
by  Councilman  and  Pearce  it  is  difficult  to  avoid  the  conclusion  that 
an  acute  interstitial  -nephritis  is  the  most  important  early  renal  lesion  of 
scarlatina. 

The  occurrence  of  a  true  glomerular  nephritis  remains,  however, 
none  the  less  a  characteristic  lesion  of  the  disease.  It  is  found  more 
commonly  late  in  the  course  of  the  attack,  after  the  establishment  of 
convalescence:  the  result,  it  may  be,  of  a  peculiar  susceptibility  on  the 
part  of  the  glomeruli,  or  of  an  unusual  degree  of  virulence  of  the  scar- 
latinal toxin,  or  its  prolonged  action. 

Macroscopically,  the  appearance  of  the  kidney  varies.  It  is  usually 
increased  in  size,  the  capsule  strips  off  easily,  in  the  acute  form;  the 
surface  is  congested  and  mottled,  and  minute  hemorrhages  may  be 
seen.  On  section  the  cortex  is  pale  and  the  markings  obscure,  the 
glomeruli  being  clearly  defined,  enlarged,  and  appearing  as  small,  gray- 
ish or  pale-yellowish  points;  occasionally  they  are  reddish  brown  in 
color.  The  pyramids  are  congested.  Histologically,  the  essential  le- 
sions are  found  in  the  glomeruli,  consisting  of  acute  proliferation  of 
the  vascular  endothelium,  hyaline  and  fibrinous  thrombosis  of  the  ves- 
sels, and  hyaline  degeneration  of  the  vessel-wall.  The  cells  of  the  cap- 
sular  epithelium  and  its  supporting  connective  tissue  may  proliferate, 
the  capsules  becoming  so  filled  with  proliferated  cells  that  they  are 
functionally  useless.  The  glomerular  lesion  is  accompanied  by  degen- 
eration and  necrosis  in  the  tubular  epithelium.  The  tubules  may  be- 
come filled  with  desquamated  epithelium,  and  haemorrhages  may  occur 
into  their  lumen. 


SCARLATINA.  223 

Briefly  we  may  summarize  the  changes  occurring  during  the  scar- 
latinal process  as  follows :  Early  acute  degenerative  -nephritis  with  cloudy 
swelling;  hyaline  and  fatty  degeneration  of  the  epithelium,  which  un- 
dergoes desquamation,,  the  changes  being  purely  degenerative;  fol- 
lowed by  acute  interstitial  nephritis,  characterized  by  a  proliferation 
of  the  cells  between  the  tubules,  with  no  glomerular  changes.  Earely 
a  true  parenchymatous  -nephritis  (acute  glomerular  nephritis),  charac- 
terized by  changes  in  the  glomeruli,  may  be  present  at  this  time, 
usually  without  evidence  of  any  proliferation  of  the  intertubular  cells; 
while  later,  after  the  establishment  of  convalescence,  we  may  find  a 
pure  glomerulonephritis,  or  even  changes  due  to  an  interstitial,  as  well 
as  a  parenchymatous,  -nephritis. 

Liver. — In  addition  to  the  changes  occurring  in  all  acute  febrile 
diseases,  Pearce  (loc.  cit.}  has  described  certain  focal  lesions  in  the  liver, 
which  were  present  in  four  out  of  twenty-two  cases,  consisting  essen- 
tially of  small  areas  of  necrotic  liver-cells  with  phagocytic  cells  in  their 
capillaries,  and  cellular  inclusions  by  the  endothelial  cells  lining  the 
capillaries.  Where  the  necrosis  is  marked,  many  of  the  hepatic  cells 
show  infiltration  with  polymorphonuclear  leucocytes.  There  is  no 
marked  reaction  about  these  areas. 

G astro-intestinal  Tract.  —  Stomach.  —  Fenwick350  demonstrated 
that  the  changes  occurring  in  the  mucous  membrane  of  the  stomach 
were  not  only  closely  analogous  to  those  seen  in  the  mucous  membranes 
elsewhere  in  scarlet  fever,  but  that  the  epithelium  of  the  gastric  mu- 
cosa  took  part  in  the  general  process  of  desquamation.  Pearce  (loc. 
cit.),  in  a  case  fatal  on  the  second  day,  found  the  surface  of  the  stom- 
ach covered  with  a  thick  layer  of  mucus  and  necrotic  epithelial  cells, 
with  marked  infiltration  of  polymorphonuclear  leucocytes;  irregular 
masses  of  bacteria — cocci — were  also  present.  The  lymph-nodules  in 
the  lower  part  of  the  mucous  membrane  were  enlarged.  Plasma-cells 
were  present  in  great  numbers  between  the  gastric  tubules.  Three 
cases  dying  at  varying  periods  before  the  fifteenth  day  showed  the 
same  changes,  though  in  less  marked  degree. 

Intestine. — Both  the  small  and  large  bowel  show  enlargement  and 
prominence  of  the  single  lymph-follicles  and  Peyer's  patches,  which 
share  in  the  hyperplasia  of  all  the  lymphoid  tissue.  There  may  be 
present,  in  addition,  changes  closely  similar  to  those  found  in  the 
stomach. 


350  Fenwick  (S.):   "Medico-Chir.   Trans."   (London,  1862),  xlvii,  p.  209. 


224  THE    ACUTE    EXANTHEMATA. 

Peritoneum  and  Serous  Membranes. — Rarely  the  peritoneum  may 
be  involved,  sharing  in  the  general  susceptibility  of  the  serous  mem- 
branes; or  any  one  of  the  large  serous  cavities  may  become  the  seat 
of  an  exudation  of  fluid,  ascites,  etc.  The  inflammatory  process  differs 
in  no  way  from  that  seen  under  other  circumstances.  The  frequency 
with  which  the  inflammatory  pleural  exudate  becomes  purulent  has 
been  noted. 

Bone-marrow.  —  In  eleven  cases  in  which  the  bone-marrow  was 
studied  by  Pearce  (loc.  cit.)  it  was  found  very  rich  in  cells,  this  being 
most  marked  in  those  cases  fatal  at  two  and  three  years  of  age.  Giant 
cells,  nucleated  red  blood-corpuscles,  and  eosinophilic  cells  were  very 
numerous;  lymphoid  cells,  neutrophilic  leucocytes,  and  abundant  cells 
closely  resembling  the  plasma-cell,  making  up  the  cellular  elements. 

Blood. — The  changes  in  the  blood  in  scarlatina  are  essentially  as 
follows:  There  is  a  reduction  in  the  haemoglobin,  varying  with  the  char- 
acter and  severity  of  the  infection.  The  specific  gravity  is  usually 
slightly  reduced,  while  the  red  blood-corpuscles  may  show  a  decided 
diminution  in  numbers,  being  in  some  instances  reduced  to  3,000,- 
000  per  cubic  centimetre.  The  white  blood-corpuscles  show  a  constant 
increase,  differing,  in  this  respect,  from  measles,  in  which  there  is  no 
leucocytosis.  Van  den  Berg,351  in  a  study  of  twelve  cases  of  scarlatina, 
found  leucocytosis  in  all,  which  began  early  and  reached  its  maximum 
by  the  fourth  or  sixth  day,  persisting,  on  an  average,  twenty  to  thirty 
days,  unless  the  course  of  the  disease  was  unusually  mild.  If  inter- 
rupted by  some  complication,  it  was  prolonged  beyond  this  period.  He 
could  determine  no  relationship  between  the  exanthem  and  the  leu- 
cocytosis, nor  was  it  affected  by  beginning  desquamation.  The  leu- 
cocytosis consists  chiefly  in  an  increase  of  the  adult  forms,  and  is  char- 
acterized by  the  persistence  of  eosinophiles.  Sevestre,352  however,  in  a 
study  of  the  blood  in  scarlatina,  says:  "A  close  relationship  has  been 
found  to  exist  between  the  leucocytosis  and  the  rash;  the  former  varies 
with  the  severity  of  the  latter,  and  with  the  fading  of  the  same;  the 
leucocytosis  shows  a  marked  diminution  in  numbers."  According  to 
Kotschetkoff,353  the  disappearance  of  eosinophiles  is  a  bad  prognostic 
sign,  except  at  the  beginning  of  the  fever.  They  are  increased  in  the 
mild,  but  absent  usually  in  the  severe,  cases. 

881  Van  den  Berg  (J.  B.  A.  M.):  Archiv  fur  Kinderh.,  1898,  vol.  xxv,  pp.  321  et  seq. 
(Which  see  for  complete  references  to  the  literature.) 

852  Sevestre  (R.):   "Saint  Bartholomew  Hospital  Reports,"  1896,  vol.  xxxii,  p.  222. 

883  See  Cabot  (R.  C.):  "Clinical  Examination  of  the  Blood"  (New  York,  1897),  p. 
177. 


SCARLATINA.  225 

ETIOLOGY. 

Bacteriology. — The  specific  cause  of  scarlet  fever,  as  of  all  the 
acute  exanthemata,  remains  undiscovered.  Notwithstanding  the  im- 
mense amount  of  work  done  by  scientific  investigators,  it  has  been  im- 
possible, up  to  the  present  time,  to  isolate,  from  an  individual  ill  with 
scarlet  fever,  that  single  element  which,  when  introduced  into  an  ani- 
mal, will  reproduce  the  disease  as  we  see  it  in  man.  By  several  early 
experimenters  (Miquel,  Williams,  Stoll354)  children  have  been  success- 
fully inoculated  with  the  disease  by  means  of  the  serum  contained  in 
the  vesicles  developing  in  the  course  of  the  fever,  by  the  blood,  or 
through  the  introduction  of  the  epidermic  scales  beneath  the  healthy 
skin. 

While  these  observations  are  extremely  interesting  and  valuable, 
as  confirming  our  views  of  the  contagiousness  of  scarlet  fever,  they  have 
no  direct  bearing  upon  the  specific  virus,  except  in  so  far  as  we  now 
know,  that  it  may  be  carried  in  this  way  from  one  individual  to  an- 
other. The  belief  that  the  poison  of  scarlet  fever  is  a  contagium  vivum 
must  be  accepted,  and  though  its  exact  identity  is  still  a  mystery,  the 
drift  of  all  our  evidence  points  strongly  to  its  bacteriological  origin, 
and  it  is  along  these  lines  that  we  may  hope  ultimately  to  find  the  solu- 
tion of  this  perplexing  problem.  The  many  forms  of  bacteria  which 
have  been  described  as  causally  related  to  this  disease  from  the  time 
of  Hallier  (1869)355  to  the  present  day  have  failed  to  stand  the  test  of 
science,  or  even  in  many  instances  to  be  confirmed  by  other  observers. 

The  tendency  of  later  investigations  has  been  rather  to  attempt 
to  establish  the  identity  of  the  particular  streptococcus  so  commonly 
associated  with  the  lesions  of  the  throat  and  the  many  complications  of 
the  disease  as  the  specific  agent. 

In  1885  Klein,356  investigating  the  epidemic  of  scarlet  fever  pre- 
vailing in  London  (Marylebone),  held  that  the  source  of  infection  was 
derived  from  the  milk-supply  from  a  dairy-farm  at  Hendon,  where  the 
cows  were  then  suffering  from  a  constitutional  disease  associated  with 
enlargement  of  the  udders,  together  with  the  development  of  vesicles 
upon  them.  As  a  result  of  his  experiments  made  with  the  streptococcus 
obtained  from  these  vesicles,  he  considered  this  disease  to  have  been 
true  bovine  scarlatina.  This  opinion,  however,  has  not  been  held  or 


354  See  Thomas  (loc.  cit.,  p.  162).' 

365  Hallier  (E.):  "Jahrb.  f.  Kinderh.,  N.  F.,"  ii,  1868-69. 

358  Klein  (E.):  "Report  of  Local  Government  Board"  (London,  1885-86),  xv. 


226  THE   ACUTE    EXANTHEMATA. 

confirmed  by  all  subsequent  observers.  Crookshank,357  in  a  similar 
epidemic  among  cows  in  Wiltshire,  records  that,  of  three  hundred  con- 
sumers of  the  milk  from  these  cows,  not  one  had  scarlet  fever.  He 
believed  that  the  disease  in  question  was  cow-pox. 

Edington,  in  1887,358  isolated  from  the  scales  and  the  blood  of 
patients  ill  with  scarlet  fever  a  bacillus  which,  when  inoculated  into 
rabbits,  produced  a  reaction,  associated  with  a  slight  rise  of  tempera- 
ture, an  erythematous  rash,  and  desquamation;  but  a  committee  ap- 
pointed by  the  Medico-Chirurgical  Society  of  Edinburgh  was  unable 
later  to  confirm  these  experiments.  Though  they  found  Edington's 
bacillus  in  three  out  of  ten  cases  of  scarlatina,  the  inoculations  into 
animals  were  negative. 

Fiessinger,359  in  1893,  formulated  a  more  definite  hypothesis  of 
the  role  of  the  streptococcus  in  scarlet  fever,  and  considers  it  to  be  the 
infecting  agent  in  the  disease. 

Dowson,360  in  the  same  year,  affirmed  that  the  scarlatinal  virus 
was  a  micro-organismal  poison  which  was  elaborated  in  the  affected 
tonsils.  This  opinion  is  in  accord  with  the  view  held  by  Lemoine,361 
that  the  throat  is  very  largely  the  point  of  entrance  of  the  disease,  and 
assigning  to  the  streptococcus  a  certain  etiological  relationship  with 
the  affection. 

More  recently  Class362  has  described  a  diplococcus,  which  he  be- 
lieves is  the  primary  etiological  element  in  scarlatina.  This  organism 
is  a  non-capsulated  diplococcus,  appearing  occasionally,  though  rarely, 
in  streptococcic  form;  polymorphous  in  character,  attaining  not  un- 
commonly under  certain  conditions  an  unusual  size.  It  is,  according 
to  this  observer,  constantly  present  in  the  pharynx  in  the  scarlatinal 
angina;  less  commonly  it  may  be  cultivated  from  the  skin;  and  on  the 
first  day  of  the  disease,  rarely  later,  from  the  blood.  Control  experi- 
ments showed  the  same  organism  present  in  8  out  of  36  cultures  from 
the  normal  pharynx,  and  in  3  out  of  23  from  the  skin. 


867  Crookshank  (E.  M.):  The  Lancet.  1887,  vol.  i,  p.  1274. 

388  Jamieson  and  Edington:  Brit.  Med.  Jour.,  1887,  vol.  i,  p.  1262-66.  See  also 
Edington:  Brit.  Med.  Jour.,  1887,  vol.  ii,  p.  394. 

488  Fiessinger:  Semaine  Med.,  July,  1893. 
•    »°  Dowson  (W.):   Med.   Chron.    (Manchester),  1893-4,   xix,  217. 

*"  Lemoine  (G.  H.):  Bull,  et  Mem.  Soc.  Med.  des  H6p.  des  Paris,  1895  and  1896. 
See  Gaz.  des  Hop.  de  Paris,  November  25,  1895,  p.  1337. 

892  Class  (W.  J.):  New  York  Med.  Record,  September,  1899,  p.  330  (original  note). 
See  also  Jour.  Amer.  Med.  Assoc.,  vol.  xxxiv,  No.  34,  1900,  pp.  476-78,  and  also  Jour. 
Amer.  Med.  Assoc.,  vol.  xxxiv.  No.  13,  1900,  pp.  799  et  aeq. 


SCARLATINA.  227 

He  has  further  produced,  by  intravenous  injection  of  cultures  of 
this  organism  into  white  swine,  a  reaction  which,  if  not  identical  with 
scarlet  fever  as  seen  in  man,  resembles  closely  the  normal  course  of  a 
scarlatinal  infection. 

A  number  of  other  investigators,  working  under  similar  condi- 
tions, have  found  a  diplococcus  apparently  identical  with  the  above 
organism. 

Baginsky  and  Sommerfield363  have  described  the  constant  occur- 
rence, in  the  pharynx  and  blood  in  scarlatina,  of  an  organism  appear- 
ing as  a  strepto-diplococcus,  the  etiological  relationship  of  which  to 
scarlet  fever  they  consider  extremely  suggestive. 

In  this  connection  it  is  interesting  to  note  that,  judging  solely 
from  the  description  given,  the  organism  described  by  them  resembles 
in  many  ways  the  diplococcus  first  described  by  Class. 

Though  it  is  as  yet  too  early  to  assert  positively  the  exact  relation- 
ship of  these  organisms  to  the  disease,  we  may  soon  be  forced  to  modify 
the  statements  made  above,  and  to  accept  the  etiological  element  as 
settled  beyond  dispute. 

Climate. — What  influence  climate  may  exert  upon  the  poison  of 
scarlet  fever  it  is  impossible  to  determine.  The  fact  that  certain  coun- 
tries enjoy  an  apparent  immunity  against  the  disease  may  be  referable 
to  climatic  conditions,  or,  on  the  other  hand,  may  be  due  to  a  peculiar 
insusceptibility  on  the  part  of  the  inhabitants.  It  remains  a  fact  that 
the  disease  is  more  or  less  prevalent  in  an  epidemic  form  throughout 
the  temperate  zones,  while  in  the  tropical  and  subtropical  countries 
its  presence  in  epidemic  form  is  almost  unknown.  Japan  enjoys  free- 
dom from  scarlet  fever,  and  in  India  the  disease  does  not  prevail  epi- 
demically among  the  native  races.  In  North  America  scarlatina  is 
much  less  common  throughout  our  Southern  States  and  southern  Cali- 
fornia, than  in  the  Northern  States;  while  in  South  America  and  in 
Europe  localities  with  apparently  the  same  climatic  conditions  as  in 
our  exempted  territority  do  not  escape  repeated  outbreaks  of  the  dis- 
ease. 

The  influence  of  the  season  of  the  year  upon  the  occurrence  of 
scarlet  fever  is  more  evident.  From  the  records  of  435  epidemics  col- 
lected by  Hirsch364  he  found  that  in  a  given  hundred  epidemics: — 


868  Baginsky  and  Sommerfleld:  Berliner  klin.  Woch.,  No.  22,  1900,  pp.  588  et  seq. 
364  Hirsch  (A.):  "Jahrsb.  ueber  die  Leistung.  u.  Fortschrit.  in  der  Gesammt.  Med." 
(Virchow-Hirsch).     Vi  Jahrg.,  vol.  xvii,  p.  131. 


228  THE    ACUTE    EXANTHEMATA. 

29.5  per  cent,  occurred  during  the  fall  months. 

24.7  "  "     winter     " 

21.8  "  "     spring     " 
24.0         "                                   "          "     summer " 

Johannessen365  has  classified  the  8608  deaths  from  scarlet  fever, 
which  occurred  in  Norway  between  the  years  1867  to  1878,  as  fol- 
lows:— 

24.1  per  cent,  occurred  during  the  fall  months   (Sept.,  Oct.,  and  Nov.). 

31.2  "  "         "     winter     "       (Dec.,  Jan.,  and  Feb.). 

24.7  "  "         "     spring     "       (March,  April,  and  May). 

19.8  "  "         "     summer"       (June,  July,  and  August). 

The  mortality  during  the  single  years  of  this  period  varied  be- 
tween 220  and  1760  deaths,  clearly  demonstrating  a  distinct,  even 
though  slight,  influence  of  the  season  of  the  year  upon  the  mortality 
and  prevalence  of  the  disease.  The  percentage  of  mortality  increased 
gradually  until  the  maximum  was  reached  during  the  winter  and  early 
spring  months,  and  fell  to  its  minimum  during  the  summer  months. 

In  England  the  prevalence  of  scarlet  fever  increases  slowly  from 
May  until  September,  when  there  is  a  rapid  extension,  which  reaches 
its  maximum  in  October  and  November,  after  which  there  is  a  gradual 
decline  until  the  minimum  is  reached  in  March  and  April.  The  statis- 
tics taken  from  Hirsch  illustrate  this  well.  The  deaths  from  scarlatina 
occurring  in  London  between  1838  and  1853  were  55,287  and  gave  the 
following  percentages  according  to  the  season  of  the  year: — 

The  deaths  occurring  during  the  fall  months  were  32.1  per  cent. 

"          "  "          "  winter     "  "       22.8     "       " 

"  spring     "  "       19.9     "       " 

"  summer "  "      25.2     "       " 

In  America,  epidemics  are  more  common  in  the  fall  and  winter 
months  than  in  the  summer,  and  the  cases  which  occur  in  winter  have 
a  tendency  to  prove  more  severe  than  those  during  the  milder  seasons. 

This  apparent  relationship  between  the  prevalence  of  the  disease 
and  the  season  of  the  year  suggests  strongly  the  influence  of  climatic 
changes,  of  temperature,  or  of  moisture  in  the  atmosphere,  upon  the 
development  of  the  poison,  but  all  attempts  to  establish  any  such  re- 
lationship upon  scientific  grounds  have  utterly  failed. 

Whatever  may  be  the  nature  of  the  scarlatinal  virus,  the  occur- 
rence of  scarlet  fever  depends  absolutely  upon  exposure  to  the  specific 

*»  Op  cit.,  p.  87. 


SCARLATINA.  229 

poison,  either  directly  or  indirectly.  In  a  great  number  of  cases  the 
spread  of  the  disease  can  be  traced  to  direct  contagion,  while  in  a  very 
considerable  number  its  origin  can  be  explained  only  by  indirect  trans- 
mission, and  in  many  instances  it  is  impossible  to  determine  the  source 
from  which  the  poison  was  derived. 

That  the  poison  of  scarlet  fever  is  less  volatile  than  that  of  measles 
has  long  been  established,  and,  while  of  great  tenacity,  it  is  not  trans- 
mitted any  great  distance  through  the  atmosphere.  In  those  instances 
in  which  infection  has  followed  direct  exposure  to  the  disease,  the  con- 
tact with  the  patient  is  usually  an  intimate  one,  though  this  is  not  al- 
ways the  case.  Our  lack  of  knowledge  of  the  specific  virus  of  scarlatina 
makes  it  impossible  to  determine  in  what  part  of  the  human  organism 
the  contagious  element  chiefly  abounds.  That  it  is  present  in  the  local 
lesions  of  the  pharynx,  in  the  discharge  from  any  mucous  cavity, — as 
in  an  otorrhcea, — in  the  normal  excretions,  and  that  it  may  in  certain 
instances  be  transmitted  by  means  of  the  epidermic  scales  we  are  cer- 
tain; and  that  it  is  carried  throughout  the  body  by  the  circulating 
blood  seems  equally  well  established. 

The  question  as  to  whether  the  poison  circulating  in  the  blood 
is  capable  of  giving  rise  to  an  intra-uterine  infection  is  one  which  has 
long  aroused  great  interest,  and,  could  we  but  prove  the  occurrence  of 
infection  during  gestation,  there  would  be  no  doubt  as  to  this  possi- 
bility. 

Unfortunately,  however,  it  is  extremely  difficult  to  do  this,  and 
the  cases  cited  in  literature  of  congenital  scarlatina  do  not  always  ex- 
clude some  other  source  of  infection  immediately  succeeding  birth. 

Thomas366  remarks  that,  owing  to  the  fact  that  niost  children  are 
born  with  a  scarlet  or  a  yellowish-red  tint  of  the  skin,  and  very  soon 
go  through  a  normal  desquamation,  it  is  difficult  to  decide  whether 
they  were  born  with  scarlet  fever  or  not.  But,  inasmuch  as  we  have 
undoubted  evidence  of  the  transmission  of  small-pox  during  intra- 
uterine  life,  can  we  not  assume  that  the  same  may  hold  true  of  scar- 
latina? On  the  other  hand,  we  know  that  mothers,  ill  with  scarlet 
fever,  have  given  birth  to  children  who  have  remained  free  from  the 
infection.367  A  case  is  cited  by  Tortual368  which  he  considers  to  have 
been  one  of  scarlatina  contracted  during  gestation,  as  follows:  A 
woman,  thirty  years  old,  who  had  never  had  scarlet  fever,  nursed  her 


366  Op.  cit.,  p.  181. 

887  See  Murchison  (loc.  cit.). 

368  See  Thomas  (loc.  cit.,  p.  182). 


230 


THE    ACUTE    EXANTHEMATA. 


Within  one  mile  of  the  hospital 286  cases. 

Cases  reported  more  than  one  mile  from  the  hospital.  .  .   757  cases. 


Total 1043  cases. 

Diagram  showing  the  Influence  of  the  Scarlet-Fever  Hospital  in 
Distributing  the  Disease.  (From  "Medical  and  Surgical  Eeports  of  the 
Boston  City  Hospital,"  1897,  page  7.) 

Thus  it  will  be  seen  that  no  cases  of  scarlet  fever  occurred  within  an 
eighth  of  a  mile  of  the  hospital,  and  only  286  cases  within  the  mile  radius,  while 
beyond  this  757  cases  were  reported.  The  influence  of  the  hospital  in  spreading 
the  disease  must  therefore  be  considered  nil. 


SCARLATINA.  231 

husband  and  son,  ill  with  the  disease,  until  shortly  before  her  confine- 
ment, and  was  delivered  of  a  boy  on  the  19th  of  September,  1823.  The 
child  could  not  swallow,  and  had  an  unusual  redness  of  the  skin,  which 
was  regarded  as  a  typical  scarlatinal  eruption.  The  mucous  mem- 
brane of  the  mouth  and  the  tongue  was  also  intensely  reddened.  The 
difficulty  of  deglutition  lasted  until  the  fifth  day;  on  the  ninth  day 
abundant  desquamation  commenced, — as  is  the  case  in  older  children, 
— and  later  a  separation  of  the  nails  of  the  fingers  and  toes  took  place, 
the  child  ultimately  recovering. 

Lemoine,369  in  support  of  his  theory  that  the  local  lesions  in  the 
pharynx  contain  very  largely  the  contagious  element,  considers  that 
the  contagion  of  the  skin  is  derived,  in  a  great  measure,  from  the  secre- 
tions of  the  throat  and  pharynx,  which  have  dried  upon  it.  In  cases 
of  scarlet  fever,  in  which  the  pharynx  is  markedly  involved,  this  is  a 
reasonable  assumption,  but  in  instances  with,  at  most,  only  a  mild 
angina  it  is  difficult  to  thus  explain  the  origin  of  the  contagion.  In 
cases  of  infection  which  occur  as  a  result  of  exposure  to  the  disease  in 
the  earliest  stages,  before  the  lesions  in  the  pharynx  are  marked,  some 
other  potent  source  of  the  poison  must  undoubtedly  be  admitted.  In 
this  connection  von  Jiirgensen  says:  "We  teach,  and  the  teaching 
seems  well  grounded,  that  it  is  only  the  dried  and  finely  powdered  par- 
ticles of  dust  which  can  be  scattered  throughout  the  atmosphere.  The 
poison  of  scarlet  fever  has  a  bodily  entity,  it  is  not  a  gas.  How,  then, 
can  it  escape  from  the  moist  cavity  of  the  mouth  of  the  patient,  and 
spread  in  this  way  through  the  air?"  Bacteriology  has  established  the 
fact  that  micro-organisms  are  not  swept  from  a  moist  surface  by  mod- 
erate currents  of  air,  and  in  scarlet  fever,  as  in  any  other  condition  in- 
volving the  pharynx,  it  must  be  chiefly  through  the  somewhat  ex- 
plosive efforts  of  coughing,  and  the  mechanical  results  of  vomiting, 
that  the  contagion  from  the  throat  is  scattered  about  the  immediate 
neighborhood  of  the  patient,  upon  the  skin,  clothes,  etc. 

Just  as  it  is  impossible  to  determine  where  in  the  human  body  the 
poison  of  scarlet  fever  is  elaborated,  and  from  what  source  it  is  largely 
derived,  so  is  it  equally  beyond  our  power  to  say  definitely  by  what 
channel  it  is  taken  up  and  absorbed.  Most  theories  advanced  are  at 
the  best  mere  conjecture.  Until  we  have  more  definite  knowledge  of 
the  nature  of  the  specific  virus  we  can  only  assume  that,  under  certain 
conditions,  the  poison  may  gain  access  through  the  respiratory  tract, 

389  Loc.  cit. 


232  THE    ACUTE    EXANTHEMATA. 

that  it  may  be  taken  in'  through  the  gastro-intestinal  tract,  or  may  be 
absorbed  through  some  break  in  the  continuity  of  either  skin  or  mucous 
membrane.  Hall,370  in  a  very  interesting  recent  article,  found,  after  an 
extensive  review  of  the  literature,  that,  "while  scarlet  fever  occurs  in 
epidemic  form  in  those  countries  where  cows'  milk  forms  a  staple  arti- 
cle of  food,  especially  among  children,  it  does  not  occur  in  countries 
where  cows'  milk  is  not  used  as  a  food,  or  where  children  are  raised  on 
mothers'  milk  only."  This  is  true  of  Japan,  where  cows'  milk  is  not 
used  and  domestic  animals  are  scarce,  and  it  is  true  in  India,  also, 
where,  though  cows'  milk  is  used,  the  children  are  nursed  by  their 
mothers  until  they  are  three  or  four  or  even  six  years  of  age. 

While  this  immunity  from  scarlet  fever,  together  with  the  absence 
of  cows'  milk  as  an  article  of  food,  may  be  simply  a  coincidence  other- 
wise explainable,  does  it  not  suggest  the  possibility  of  infection  through 
the  gastro-intestinal  tract  as  perhaps  the  chief  source? 

The  contagion  of  scarlet  fever  may  be  transmitted  by  healthy  in- 
dividuals as  well  as  inanimate  objects,  such  as  books,  clothes,  toys, 
letters,  etc.  It  is  also  held  that,  in  some  instances,  animals,  such  as 
dogs  and  cats,  may  be  the  carriers  of  the  poison,  though  whether  they 
themselves  become  infected  with  a  true  scarlatina  remains  an  open 
question.  Those  instances  reported  in  literature,  of  exanthemata  in 
animals,  associated  with  fever  and  desquamation,  cannot  be  accepted 
as  typical  of  scarlet  fever  unless  the  specific  infective  agent  be  iso- 
lated and  found  to  fill  the  conditions  required  by  bacteriology.  The 
fact  that  the  poison  of  scarlet  fever  is  less  volatile  than  in  the  case  of 
the  other  acute  exanthemata  is  well  illustrated  by  the  proof  constantly 
afforded  in  the  outbreaks  of  the  disease  in  children's  hospitals,  or  pri- 
vate houses,  where,  if  the  patient  be  promptly  isolated,  infection  occurs 
only  in  those  exposed  before  isolation  has  been  established.  A  rigid 
quarantine  will  prevent  further  spread  with  far  greater  certainty  than 
is  the  case  in  small-pox  or  measles. 

The  case  cited  by  Forchheimer  (loc.  cit.,  p.  15),  in  which  children 
in  one.  house  talked  through  the  open  windows  to  other  children,  ill  or 
convalescent  from  scarlet  fever,  in  the  next  house  at  a  distance  of  only 
nine  feet  and  did  not  contract  the  disease,  is  a  further  proof  of  the 
limited  diffusion  of  the  contagion  about  the  immediate  neighborhood 
of  the  patient. 

As  an  example  of  the  means  by  which  the  contagion  may  be  trans- 


178  Hall  (H.  O.):  New  York  Med.  Record,  November  11,  1899,  p. 


SCARLATINA.  233 

mitted,  the  instance  cited  by  von  Hildebrand,371  in  which  a  coat,  that 
had  been  exposed  to  the  infection  a  year  and  a  half  before,  was  the 
cause  of  a  fresh  outbreak,  is  well  verified.  The  case  cited  by  W. 
Boeck372  illustrates  not  only  the  means  of  conveyance  of  the  disease, 
but  the  great  tenacity  of  the  poison  as  well.  Some  children  were  given 
permission  to  play  with  the  various  articles  put  away  in  an  old  writing- 
desk.  In  one  of  the  drawers  of  this  desk  were  the  locks  of  hair  that  had 
been  taken  twenty  years  before  from  two  children  who  had  died  of  scar- 
let fever,  and  which  had  not  been  disturbed  since  that  time.  The  chil- 
dren found  these  locks  of  hair,  took  them  out  and  examined  them,  and 
subsequently  developed  scarlet  fever.  In  this  instance  the  proof  was  as 
conclusive  as  it  could  possibly  be;  for  these  were  the  first  cases  of 
scarlatina  in  the  city.  In  a  further  series  of  cases  quoted  by  Thomas373 
the  following  articles  were  considered  to  have  been  the  means  by  which 
the  contagion  was  transferred:  a  letter,  a  shawl,  a  box  of  toys,  the 
cushions  of  a  rocking-chair,  and  a  violin.  Even,  in  one  case,  a  piano 
is  said  to  have  harbored  the  poison.  The  danger  of  a  spread  of  the 
infection  through  the  linen  and  bedding  of  a  patient  is  a  real  one,  and 
often  necessitates,  in  addition  to  the  careful  disinfection  of  the  linen, 
a  separation  of  the  linen  of  scarlatinal  patients  in  a  hospital  from  that 
used  in  the  general  wards.  Instances  in  which  a  healthy  individual  has 
carried  the  contagion  are  many,  occurring  not  infrequently  through 
the  agency  of  those  in  attendance  on  the  patient.  The  case  reported 
by  Dr.  Loeb,374  of  Worms,  in  which  his  little  girl  contracted  scarlatina, 
is  a  most  convincing  proof. 

Dr.  von  Essingen  went  from  Worms  to  Mannheim,  visiting,  while 
there,  three  children  ill  with  scarlet  fever.  He  returned  to  Worms,  and 
on  the  afternoon  of  the  same  day,  while  paying  a  friendly  call  at  the 
house  of  his  friend  Dr.  Loeb,  took  the  latter's  little  daughter  upon  his 
lap,  holding  her  for  some  time.  On  the  following  day  she  developed  a 
typical  attack  of  scarlatina.  Dr.  von  Essingen  had  not,  it  seems, 
changed  his  clothes  between  the  visit  paid  in  Mannheim  and  the  call 
in  Worms.  There  was,  previous  to  this,  so  far  as  could  be  ascertained, 
no  scarlet  fever  in  Worms. 

An  instance  in  which  two  individuals,  who  remained  well,  were  the 


371  See  von  Jiirgensen  (loc.  cit.,  p.  35). 

872  See  Johannessen  (loc.  cit.,  pp.  162  and  163). 

373  Thomas  (loc.  cit.,  p.  164). 

874  Loeb  (M.):   "Jahrb.  f.  Kinderheil.,  N.  F.,"  vol.  ix,  p.  1?4. 


234  THE    ACUTE    EXANTHEMATA. 

carriers  of  the  contagion  is  cited  by  Allbutt,375  and  is,  so  far  as  we  have 
been  able  to  find  in  literature,  the  only  example  of  such  an  occurrence. 

"A  father,  staying  in  the  house  of  a  friend,  met,  on  the  platform 
of  a  railway  station  thirty  miles  away,  his  son,  who  came  to  this  station 
from  a  school  where  scarlet  fever  was  then  prevalent.  The  two  spent 
an  hour  and  a  half  together  and  then  returned  to  their  respective  quar- 
ters. Within  the  next  four  days,  the  lady  of  the  house  to  which  the 
father  returned  fell  ill  and  died  of  malignant  scarlet  fever.  The  father 
and  son  remained  well."  Although  every  effort  was  made  to  find  the 
cause  elsewhere,  no  other  source  of  infection  than  the  above  could  be 
discovered.  That  milk  may,  in  certain  instances,  be  the  source  of  in- 
fection has  been  clearly  proved,  though  it  is  highly  probable  that  it 
acts  merely  as  a  carrier  of  the  contagion,  and  bears  no  etiological  re- 
lationship to  the  development  of  the  specific  virus.  In  England, 
America,  and  Germany  definite  outbreaks  of  scarlet  fever  have  been 
traced  to  a  contaminated  milk-supply,  though  the  attempts  to  estab- 
lish any  definite  scientific  connection  with  a  disease  existing  at  the 
same  time  in  a  particular  herd  of  cows  has  failed.  In  almost  all  in- 
stances it  has  been  shown  that  the  contagion  of  the  milk  arose  through 
its  exposure  to  the  disease  in  man,  and,  when  it  has  not  been  possible 
to  do  this,  we  must  assume  that  some  such  outside  agency  has  been 
the  source  of  infection.  Knowing  the  great  tenacity  of  the  poison  of 
scarlet  fever,  the  possibility  of  such  undetected  sources  of  contagion 
must  be  granted. 

In  France,  on  the  other  hand,  Moizard376  states  that  outbreaks  of 
scarlatina  traceable  to  an  infected  milk-supply  have  never  been  ob- 
served; and  regards  this  alleged  relationship  in  countries  where  scarlet 
fever  is  extremely  common  as  of  very  little  etiological  value.  May 
there  not  be,  however,  some  relationship  between  the  freedom  of  France 
in  this  respect,  and  the  suggestive  conclusions  arrived  at  by  Hall  (loc. 
cit.).  It  is  well  known  that  in  France,  in  the  vast  majority  of  cases, 
children  are  nursed  by  their  mothers,  or  by  wet-nurses,  for  in  almost 
no  other  country  has  the  system  of  wet-nursing  been  carried  to  the  same 
extent.  Hall  further  states  "that,  in  countries  where  goats'  milk  and 
asses'  milk  are  used  as  a  food,  scarlet  fever  is  unknown."  It  is  difficult 
to  believe  that  cows'  milk  alone  is  capable  of  becoming  a  source  of  con- 
tagion. If  cows'  milk  may  be  the  carrier  of  the  poison,  why  not  goats' 
and  asses'  milk  also?  These  are  questions  that  time  alone  can  answer. 

875  See  Allbutt's  "System  of  Medicine"  (loc.  cit.,  p.  129). 
874  Loc.  cit.,  p.  118. 


SCARLATINA.  235 

The  great  danger  in  an  infected  milk  lies  in  taking  it  in  the  raw 
or  natural  state;  boiling  has  been  shown  to  do  away  with  the  power  of 
infection. 

The  two  cases  cited  above  (see  page  233),  as  illustrating  the  means 
of  the  spread  of  scarlatina,  serve  well  also  to  demonstrate  the  great 
tenacity  of  the  poison,  which  often,  in  spite  of  vigorous  efforts  to  de- 
stroy it,  remains  latent,  and  at  some  subsequent  time  lights  up  a  fresh 
epidemic,  the  exact  source  of  which  it  may  be  most  difficult  to  deter- 
mine. Murchison  (loc.  tit.}  cites  an  interesting  instance  of  the  tenacity 
of  the  specific  virus,  occurring  in  spite  of  the  best  conditions  for  thor- 
ough disinfection.  During  an  epidemic  of  scarlet  fever  in  St.  Thomas's 
Hospital,  London,  one  ward  was  set  apart  for  this  disease.  For  two 
years  subsequent  to  this' outbreak,  though  this  ward  had  been  thor- 
oughly cleaned,  disinfected,  and  even  painted  immediately  after  the 
subsidence  of  the  epidemic  and  yearly  thereafter,  all  the  children  sent 
into  it  developed  scarlatina. 

Hatfield377  relates  an  extraordinary  case,  in  which  the  contagion 
survived  two  generations,  being  packed  away  in  a  chest  of  clothes  for 
thirty-five  years,  after  this  lapse  of  time  communicating  the  disease  to 
a  grandchild,  for  whom  some  of  the  grandfather's  clothes  had  been 
made  over. 

From  these  cases  it  is  evident  that  the  poison  of  scarlet  fever 
may  retain  its  contagious  properties  indefinitely,  and  may  exist  for 
years  under  circumstances  which  absolutely  preclude  any  fresh  access 
of  contagion.  This  tenacity  seems  to  depend  in  no  way  upon  the  sur- 
rounding conditions,  but  rather  upon  the  essential  virulence  of  the  con- 
tagion alone. 

When  Contagious. — In  spite  of  the  conflicting  statements  of  many 
observers  as  to  the  period  during  which  the  disease  may  be  transmitted, 
the  weight  of  the  evidence  establishes  the  fact,  beyond  a  doubt,  that 
scarlatina  is  contagious  from  the  appearance  of  the  earliest  symptoms 
until  after  desquamation  is  complete.  Eichhorst  (loc.  cit.,  p.  230)  says 
that  it  is  least  contagious  during  the  period  of  incubation,  most  pro- 
nounced at  the  time  of  the  eruption,  and  that,  with  the  establishment 
of  convalescence  and  advancing  desquamation  the  power  of  contagion 
steadily  diminishes.  Osier378  states  that  "the  contagion  of  scarlet  fever 
is  probably  not  developed  until  the  eruption  appears,  and  is  to  be  par- 


s'77 Hatfield  (M.  P.):   "Scarlet  Fever,"  in  "American  Text-book  of  the  Diseases  of 
Children"   (Philadelphia,  1894),  p.  157. 

378  Osier  (W.):  "Practice  of  Medicine"   (New  York,  1896),  p.  71. 


236  THE   ACUTE    EXANTHEMATA. 

ticularly  dreaded  during  desquamation";  while  Holt  affirms  that  in- 
fection is  doubtless  most  active  during  the  febrile  period,  and  places 
the  average  duration  of  the  contagious  period  at  six  weeks.  According 
to  Sanne,379  contagion  is  most  to  be  dreaded  during  the  period  of  des- 
quamation. Lemoine,380  on  the  other  hand,  has  reported  several  cases 
in  which  soldiers,  convalescent  from  scarlet  fever,  had  returned  either 
to  their  barracks  or  home  before  desquamation  was  complete,  and  yet 
did  not  spread  the  disease.  In  a  disease  in  which  individual  suscepti- 
bility and  idiosyncrasy  play  so  large  a  part,  it  is  necessarily  difficult  to 
form  an  accurate  judgment  in  isolated  cases;  but  that  scarlatina  may 
be  contracted  during  the  earliest  stages  of  an  attack  is  proved  by  the 
celebrated  case  quoted  by  Trousseau.381  A  London  merchant,  who  had 
been  spending  the  winter  in  Pau  with  one  of  his  daughters,  planned, 
on  his  return  to  England,  to  stop  over  in  Paris  for  several  days.  His 
eldest  daughter,  who  had  been  keeping  house  in  England  during  his 
absence,  anxious  to  meet  her  father  and  sister,  went  on  to  Paris.  While 
crossing  the  channel  she  was  seized  with  fever  and  a  sore  throat.  Seven 
or  eight  hours  later  she  arrived  in  Paris,,  reaching  the  hotel  but  a  short 
time  after  her  sister  and  father  had  arrived  from  Pau,  and  came  down 
with  a  severe  attack  of  scarlet  fever.  Within  twenty-four  hours  it  de- 
veloped in  her  sister  as  well.  There  had  been  no  scarlet  fever  in  Pau, 
but  it  was  epidemic  at  this  time  in  London. 

Evidence  of  the  transmissibility  of  the  contagion,  even  after  the 
disappearance  of  all  the  signs  of  desquamation,  is  not  wanting.  In 
proof  of  this  Bond382  cites  the  following  instance:  A  child  was  sent  out 
from  the  hospital  six  weeks  after  the  onset  of  a  mild  attack  of  scarlet 
fever,  without  having  shown  for  fifteen  days  the  slightest  trace  of  des- 
quamation. He  returned  home,  every  necessary  precaution  as  to  dis- 
infection having  been  carried  out,  and  was  allowed  to  occupy  the  same 
bed  with  his  small  sister,  who,  five  days  later,  developed  scarlet  fever. 

Wood383  relates  an  almost  parallel  instance.  In  these  cases  the 
tenacity  of  the  contagious  element  seems  to  favor  the  theory  of  Le- 
moine,  that  the  poison  is  very  largely  present  in  the  throat,  and  in  this 
locality  may  remain  virulent  after  all  evidence  of  the  disease  has  disap- 


378  Sanne  (A.):  In  Barthez  et  Sanne:  "Traite  Clinique  et  Pratique  des  Maladies  des 
Enfants"  (Paris,  1891). 

880  Lemoine  (G.  H.):  Bull,  et  Mem.  Soc.  Med.  des  H6p.  de  Paris,  1895,  iii  S.,  xii,  pp. 
738  et  seq. 

881  See  Trousseau  (loc.  cit.,  p.  172). 

882  Bond:   Brit.   Med.  Jour.,   February,   1887,  p.   277. 
388  Wood  (H.  C.):  Therap.  Gaz.,  vol.  i,  1889,  p.  739. 


SCARLATINA.  237 

peared.  Situated  here,  it  must  escape  the  general  disinfection  to  which 
the  body  is  submitted.  Under  the  above  circumstances  it  is  difficult,  at 
least,  to  assume  the  epidermic  scales  to  have  been  the  carrier  of  the 
contagion.  Thomas  (loc.  cit.,  p.  178)  believes  that  there  is  no  satisfac- 
tory evidence  to  prove  that  the  contagion  is  situated  either  exclusively 
or  even  chiefly  in  the  epidermis,  and  that  it  may  be  presumed  that  the 
contagion  enters  from  the  blood  into  all  the  secretions  and  excretions 
of  the  patient.  Thus,  it  is  evident  that  the  contagion  of  scarlet  fever 
may  be  transmitted  from  the  moment  of  appearance  of  the  earliest 
symptoms  until  after  all  evidence  of  the  disease  has  disappeared,  though 
it  still  remains  impossible  to  determine  the  exact  moment  at  which 
the  contagiousness  ceases. 

Individual  Predisposition. — In  general,  the  predisposition  to  scar- 
let fever  is  much  less  common  than  in  the  case  of  small-pox  and  meas- 
les, while,  at  the  same  time,  individual  susceptibility  varies  greatly  both 
as  regards  exposure  and  the  severity  of  the  infection.  Certain  indi- 
viduals, though  repeatedly  exposed,  and  even  though  they  may  be  the 
means  of  spreading  the  contagion  to  others,  do  not  themselves  con- 
tract the  disease.  On  the  other  hand,  the  members  of  some  families 
show  a  marked  susceptibility  to,  and  but  slight  powers  of  resistance 
against,  the  virulence  of  the  poison.  In  some  instances  an  individual 
who  has  been  repeatedly  exposed  to  an  intensely  severe  infection  es- 
capes, only  to  contract  the  disease  at  some  later  time.  That  individual 
susceptibility  does  not  always  bear  a  distinct  relationship  to  the  viru- 
lence of  the  contagion  is  borne  out  by  those  not  infrequent  cases  in 
which  two  members  of  the  same  family  contract  the  disease  from  the 
same  source,  and  yet  show  a  great  difference  in  the  severity  of  the  in- 
fection; or  even  in  those  instances  in  which,  though  exposed,  but  one 
individual  succumbs  to  the  poison.  In  the  history  of  epidemics  of 
scarlet  fever  appearing  in  a  given  locality  after  a  long  period  of  free- 
dom from  the  disease,  an  apparent  immunity  on  the  part  of  some  in- 
dividuals has  been  observed  which,  under  the  influence  of  the  presence 
of  the  contagion,  has  gradually  diminished  and  given  place,  in  subse- 
quent outbreaks,  to  a  more  general  predisposition  on  the  part  of  the 
individuals  in  those  households  which  had  hitherto  escaped.  That  the 
conditions  under  which  an  outbreak  of  scarlatina  occurs,  whether  in 
a  scattered  or  a  crowded  population,  should  in  some  measure  influence 
the  predisposition  to  the  infection,  would  seem  at  least  plausible,  but 
any  such  definite  relationship  cannot,  in  every  instance,  be  established. 

In  the  epidemic  occurring  in  the  Canary  Islands  (see  p.  171), 


238  THE    ACUTE    EXANTHEMATA. 

where,  for  a  lapse  of  fifty-seven  years  there  had  been  no  scarlet  fever, 
this  is  well  illustrated  by  the  villages  of  Haldersvig  and  Eide,  both  sub- 
jected to  like  conditions  of  climate,  temperature,  soil,  etc.;  the  former 
having  a  rather  scattered  population,  while  the  latter  was  very  closely 
built  up.  In  Haldersvig,  with  161  inhabitants,  there  were  58  cases  of 
scarlatina  (36  per  cent.).384  In  Eide,  with  305  inhabitants,  there  were 
6  cases  of  scarlatina  (2  per  cent.).  Contrasting  the  susceptibility  of 
these  same  islanders  to  the  contagion  of  scarlatina  and  measles,  the  dif- 
ference is  striking. 

In  1846,385  during  an  epidemic  of  measles  in  these  islands,  which 
lasted  but  a  comparatively  short  time,  three-fourths  of  the  entire  popu- 
lation contracted  the  disease;  while  during  this  epidemic  of  scarlet 
fever,  which  continued  over  many  months,  but  one-eleventh  of  the 
whole  population  suffered. 

Social  conditions,  though,  in  a  measure,  influencing  the  mortality 
of  scarlet  fever,  seem  to  exert  no  appreciable  influence  upon  individual 
susceptibility.  Eich  and  poor  alike,  when  exposed,  show  no  marked 
difference  in  this  respect.  The  statements  of  various  authorities  differ 
greatly  on  this  point:  a  fact  which  seems  in  itself  proof  that  there  can 
be  no  great  difference  in  the  predisposition  of  the  better  classes  and 
that  of  less  favored  individuals.  Forchheimer  (loc.  tit.,  p.  22)  has  even 
demonstrated  that  in  Berlin,  from  1876  to  1883,  the  mortality  was  less 
among  those  occupying  the  lower  than  in  those  occupying  the  upper 
floors  of  the  same  tenements,  being  greatest  upon  the  fourth  floor, 
which,  though  generally  more  crowded  with  tenants,  had  surely  a  better 
air  than  the  lower  stories,  and  admits  of  no  traceable  connection  with 
the  soil. 

That  the  mortality  from  scarlet  fever  is  greater  among  the  poor 
is  due  to  the  fact  that  they  cannot  avail  themselves  of  the  same  care 
and  skill  which  is  afforded  the  rich. 

Age  has  a  very  pronounced  influence  upon  susceptibility  to  the 
contagion  of  scarlet  fever,  childhood,  in  a  marked  degree,  predisposing 
to  the  disease.  That  it  occasionally  occurs  late  in  life,  as  well  as  in  the 
earliest  months,  is  well  established;  though  the  statement  made  by 
some  writers,  that  scarlet  fever  may  be  congenital,  seems  to  us,  in  the 
light  of  our  present  evidence,  untenable.  The  figures  collected  by 
Hoff386  from  the  outbreak  in  the  Canary  Islands,  are  interesting: — 


884  See  von  JUrgensen  (loc.  cit.,  p.  6). 
888  Ibid.,  p.  9. 
s*Ibid.,  p.  10. 


SCARLATINA. 


239 


In  Thorshavn,  out  of  343  inhabitants  between  the  ages  of  0  and 
20  years,  193  (or  56.3  per  cent.)  contracted  scarlatina. 

Out  of  582  inhabitants  over  40  years  of  age,  44  (or  only  7.6  per 
cent.)  developed  the  disease. 

Murchison's387  statistics  of  148,829  deaths  from  scarlatina  in  Eng- 
land and  Wales  in  1847,  and  from  1855  to  1861  illustrate  the  frequency 
of  the  disease  at  different  ages: — 


MALES.      FEMALES. 


Under 

1     year, 

9,999  5,575.  . 

.  .  .   4,424  

From 

1-2     years, 

20,975 

" 

2-3 

23,842 

" 

3-4 

22,528 

6C 

4-5 

17,726 

Under 

5 

95,070  49,157.  .  . 

.  .  45,899  

From 

5-10 

38,591 

" 

10-15 

8,676 

Total, 

5-15 

47,267  23,242.. 

..24,025  

From 

15-25 

3,871 

" 

25-45 

1,971 

" 

45-65 

516 

.    " 

65-85 

118 

" 

85-95 

4 

Over 

95 

6 

From 

15-95       " 

6,492  2,964.  . 

.  .    3,528  

cent. 


63.8  per  cent. 


31.7  per  cent. 


Total 75,373 73,456 

Johannessen388  has  further  classified   1040  deaths  from  scarlet 
fever  in  Norway  between  the  years  1862  and  1878  as  follows: — 

During  the  first  year  1st  month     0  cases. 
"      2d-3d       "      3       " 
"      4th-6th    "12       " 

"      7th-12th  "87       "     9.^  per  cent. 

During  the  second  year 43.0     "       " 

"     4th-5th     "     22.6     "       " 

From        "     5th-10th  "     20.5     "       " 

"  llth-15th  "     2.3  per  mille. 


387  See  Murchison:  The  Lancet  (loc.  cit.). 

388  See  Johannessen  (op.  cit.,  p.  86). 


240  THE    ACUTE    EXANTHEMATA. 

Tripe,389  in  a  given  1000  deaths  from  scarlet  fever,  has  arranged 
them  according  to  the  years  at  which  they  occurred: — 


During  the  1st  year   65  deaths. 
From      1-2  years  147   " 
2-3    "   165   " 

3-4 

"   149   " 

4-5 

"   120   " 

5-15 

"   316   " 

15-25 

22   " 

25-45 

14   " 

45-65 

2   " 

Total 1000 

From  the  above  figures  it  is  evident  that  the  greatest  number  of 
cases  occur  between  the  ages  of  one  and  five,  while  next  in  frequency 
comes  the  period  between  five  and  fifteen,  after  which  the  number  of 
cases  rapidly  diminishes.  It  is  seen  that  the  percentage  during  the 
first  year  is  comparatively  small,  being  but  6.7  per  cent.,  9.3  per  cent., 
and  6.5  per  cent.,  respectively. 

The  influence  of  sex  exerts  but  very  slight  effect  upon  the  indi- 
vidual predisposition  to  scarlatina.  Up  to  the  age  of  fifteen  the  greater 
number  of  cases  are  seen  in  males;  after  this  period  there  is  a  slight 
increase  in  favor  of  the  opposite  sex,  though  the  total  percentage  for 
both  sexes  is  commonly  greatest  in  males. 

In  the  figures  given  by  Murchison  (see  above)  the  results  are:  50.7 
per  cent,  for  males,  as  against  49.3  per  cent,  for  females. 

Certain  other  conditions  very  markedly  increase  the  predisposition 
to  scarlatina.  Among  these  convalescence  from  surgical  operations  and 
the  existence  at  the  time  of  exposure  of  accidental  wounds  deserve  men- 
tion. Exceptions,  here  as  elsewhere,  occasionally  occur,  and  the  writer 
well  remembers  an  instance,  in  which  he  was  present  at  a  laparotomy, 
the  sole  onlooker  in  a  small  operating-room,  and  six  hours  later  devel- 
oped a  severe  septic  scarlatina,  while  the  patient,  unconsciously  ex- 
posed in  this  way,  remained  well  and  made  a  good  recovery. 

The  danger  ^f  confusing  the  various  types  of  post-operative  or 
traumatic  erythema  with  the  true  scarlatinal  eruption  must  be  ad- 
mitted; and  so  long  as  the  diagnosis  of  "surgical  scarlatina"  continues 
to  be  made  on  the  basis  of  the  rash  alone,  such  mistakes  must  inevitably 
occur. 


388  Tripe  (J.  W.):  "The  Mortality  from  the  Eruptive  Fevers  at  Different  Periods  of 
the  Year"  (London,  1857). 


SCAKLATINA.  241 

The  term  "scarlet  fever/'  however,  must  be  limited  to  those  cases 
in  which,  in  addition  to  the  eruption,  other  typical  symptoms  of  the 
disease,  such  as  angina,  glandular  swelling,  desquamation,  or  even  sub- 
sequent nephritis,  are  present.  Hoffa390  has  divided  these  post-opera- 
tive scarlatinoid  erythemas  into  three  classes:  the  congestive,  the  toxic, 
and  those  associated  with  general  sepsis.  (1.  Erythema  Congestivum. 
2.  Erythema  Toxicum.  3.  Affections  of  the  skin  associated  with  sep- 
sis.) 

Sir  James  Paget391  holds  that,  in  the  cases  of  post-operative  scar- 
latina described  by  him,  the  patients  were  infected  prior  to  operation, 
and  that  the  onset  of  the  attack  was  hastened  by  the  necessarily  low- 
ered vitality  of  the  patient.  Knowing  the  tenacity  of  the  scarlatinal 
virus,  it  is,  of  course,  impossible  to  exclude  a  previous  infection  in  all 
such  cases;  but,  as  a  rule,  whether  exposed  previous  or  subsequent  to 
the  operation,  the  susceptibility  of  the  individual  to  the  poison  is 
usually  increased.  Henoch392  has  called  attention  to  the  great  sus- 
ceptibility of  children,  the  subjects  of  operative  wounds  for  phimosis, 
tracheotomy,  and  of  wounds  about  the  eyes;  while  Hagenbach393  has 
further  noticed  the  unusually  short  period  of  incubation,  in  addition 
to  the  increased  susceptibility  of  patients  with  tracheotomy  wounds 

Bruner394  has  reported  five  cases,  in  which,  fallowing  local  post- 
operative erysipelas,  a  general  scarlatinal  attack  has  developed.  From 
all  the  evidence  we  are  justified  in  assuming  that  the  presence  of  acci- 
dental or  operative  wounds  in  some  way  lessens  the  resistance  of  the 
individual  against  the  scarlatinal  poison.  With  the  modern  methods  of 
thorough  and  exact  asepsis,  and  antisepsis,  it  has  been  shown  that,  in 
the  case  of  surgical  wounds,  subsequent  scarlatinal  infection  is  becom- 
ing of  far  less  common  occurrence. 

Puerperal  Scarlatina. — Henoch395  is  of  opinion  that  the  well-rec- 
ognized susceptibility  to  scarlatina  of  women  recently  confined  is  refer- 
able, in  some  measure,  to  the  same  conditions  which  prevail  in  the 
surgical  cases,  namely:  the  existence  of  a  large  surface  admitting  of 
ready  absorption  of  the  poison,  associated  with  weakened  power  of  re- 
sistance on  the  part  of  the  individual.  Here,  again,  we  must  distin- 


380  Hoffa  (Albrecht) :   In  von  Volkmann's  Sammlung  klin.  Vortrage,   No.  292  (Chi- 
rurgie,  No.  90),  1886-87,  pp.  2679  et  seq. 

381  Paget  (Sir  James):  Brit.  Med.  Jour.,  1864,  ii,  237. 

382  See  Henoch  (Vorles.,  Joe.  cit.,  p.  682). 

383  Hagenbach  (loc.  cit.,  p.  115). 

394  Bruner  (K.):  Berliner  klin.  Woch.,  1895,  No.  22,  pp.  469  et  seq. 
386  See  Henoch  (ibid.,  p.  682). 

16 


242  THE   ACUTE    EXANTHEMATA. 

guish  the  so-called  "puerperal  scarlatina,"  which  is  but  the  expression 
of  a  severe  general  septic  infection,  with  an  erythematous  rash  simu- 
lating a  scarlatinal  eruption,  from  true  scarlet  fever.  Von  Jiirgensen306 
calls  attention  to  the  fact  that  the  greatest  number  of  cases  of  scarlet 
fever  occurring  during  the  lying-in  period  are  reported  from  England; 
and  considers  it  established  beyond  a  doubt,  from  the  statistics  pub- 
lished by  Braxton-Hicks  and  others,  that  the  women  of  Great  Britain 
are  more  often  subject  to  puerperal  erythemas  than  the  women  of  Ger- 
many; but  is  inclined  to  question  the  significance  of  these  erythemas 
in  every  case.  According  to  Eunge,397  the  existence  of  scarlatina  is  not 
an  altogether  infrequent  complication  of  the  puerperium,  but  he  says 
this  is  apparently  much  more  frequently  seen  in  England,  though  iso- 
lated cases,  and  even  epidemics  in  institutions,  have  been  reported  in 
Germany  and  from  Switzerland. 

Of  the  susceptibility  of  lying-in  women  to  the  poison  of  scarlatina, 
there  can,  however,  be  no  question;  and  the  number  of  cases  reported 
in  literature  establish  beyond  a  doubt  its  all  too  frequent  occurrence. 
It  is,  of  course,  possible  that  many  cases  of  so-called  scarlatina  are,  in 
reality,  simple  septic  infection.  Infection  may  occur  during  preg- 
nancy, or  at  the  time  of  confinement.  As  a  rule,  the  disease  develops 
during  the  first  days  of  the  puerperium,  and  follows  the  same  course 
seen  in  adults  under  normal  circumstances,  with  the  exception  that 
the  angina  may  be  less  marked,  and  the  intestinal  symptoms  not  infre- 
quently more  pronounced. 

The  existence  of  other  infectious  diseases  in  an  individual  at  the 
time  of  exposure  exerts  no  special  disposition  either  toward  or  against 
the  poison  of  scarlet  fever.  Occasional  instances  are  reported  in  which 
scarlatina  has  developed  during  or  closely  following  an  attack  of  mea- 
sles, variola,  varicella,  and  typhoid  fever,  and  more  rarely  mumps  and 
erysipelas.  In  such  cases  it  usually  runs  its  course  modified  but  slightly 
by  the  pre-existing  infection. 

Acquired  Immunity. — As  a  rule,  one  attack  of  scarlatina  protects 
against  a  subsequent  infection,  though  the  immunity  is  by  no  means 
an  assured  one,  and  second,  and  even  third,  attacks  have  been  reported. 
In  considering  the  question  of  a  positive  diagnosis  of  a  second  attack 
one  must  exclude,  of  course,  all  conditions  which  are  dependent  in  any 
way  upon  the  first  attack,  and  which  should  be  considered  as  relapses. 

A  second  attack  can  only  justly  be  held  to  be  such,  when  it  ap- 

3S*  Von  Jiirgensen  (loc.  cit.,  p.  23). 

397  Runge  (M.):  "Lehrbuch  der  Geburtshulfe"  (Berlin,  1898),  p.  564. 


SCARLATINA.  243 

pears  some  time  after  the  disappearance  of  the  symptoms  of  the  first 
attack,  and  can  have  no  possible  relationship  with  it.  In  this  connec- 
tion it  is  interesting  to  note  that  Henoch398  has  seen  but  one  authentic 
case  of  a  second  attack  of  scarlatina,  and  further  cautions  against  con- 
fusing the  simple  febrile  erythemas  with  the  true  scarlatinal  eruption. 
Instances  of  a  third,  and  even  a  fourth,  attack  have  been  reported  by 
Murchison  3"  and  Stiebel,400  respectively.  According  to  Korner,401 
when  a  second  attack  occurs,  it  usually  follows  from  two  to  six  years 
after  the  first,  which  most  frequently  occurs,  in  such  cases,  before  the 
age  of  ten.  The  second  outbreak  is,  as  a  rule,  no  milder  than  the  first, 
and  may  even  be  much  more  severe. 

Epidemic  Type. — There  are  certain  characteristics,  if  such  we  can 
call  them  (for,  in  reality,  it  is  the  absence  of  distinct  characteristics), 
which  give  to  the  symptom-complex  known  as  scarlatina  a  unique  place 
among  infectious  diseases. 

In  our  present  ignorance  as  to  the  precise  nature  of  the  scar- 
latinal virus  and  the  conditions  influencing  its  life-history,  an  attempt 
to  establish  a  relationship  between  sporadic  cases  or  single  epidemics 
of  this  disease  and  the  conditions  under  which  they  occur,  and  which 
should,  we  assume  in  some  measure  at  least,  modify  the  prevailing  type, 
must  be,  to  a  large  extent,  provisional. 

•  It  is  as  impossible  to  explain  the  great  variation  seen  in  different 
•epidemics,  which  may  range  in  mortality  from  3  to  30  per  cent., 
as  it  is  to  explain  such  great  variation  in  the  severity  of  the  in- 
fection in  individual  cases,  often  seen  in  members  of  the  same  house- 
hold. Scarlet  fever  shows  a  variation  in  the  epidemic  type  far  more 
striking  than  that  seen  in  any  other  disease:  a  variation  controlled  ap- 
parently by  no  laws  and  governed  by  no  semblance  of  regularity.  Dur- 
ing the  early  years  of  its  appearance  on  the  Xorth  American  continent 
the  disease  prevailed  in  a  very  mild  type;  later,  epidemics  of  great 
malignancy  occurred  which,  in  turn,  were  succeeded  during  the  30's  by 
outbreaks  of  a  type  so  mild  that  the  contagiousness  of  the  disease  was 
questioned.  In  Ireland402  the  same  striking  variation  was  seen  between 
the  epidemics  which  devastated  the  country  from  1800  to  1804,  and 
the  long  subsequent  period  of  mild  outbreaks  lasting  until  1831,  fol- 


398  See  Henoch  (loc.  cit.,  p.  683). 
398  See  Murchison  (loc.  cit.). 

400  See  Thomas  (loc.  cit.,  p.  192). 

401  Korner:   "Jahrb.  f.  Kinderh.,  N.  F.,"  vol.  ix,  p.  362. 

402  See   Graves  and   Gerhard:    "System  of  Clinical  Medicine"    (Philadelphia,   1848), 
pp.  421  et  seq. 


244  THE    ACUTE    EXANTHEMATA. 

lowed  in  this  year  and  again  in  1834  by  epidemics  of  frightful  malig- 
nancy. Trousseau403  has  called  attention  to  the  sudden  and  rude  con- 
tradiction of  his  master  Brettoneau's  teaching,  who  had  not  seen  a 
death  from  scarlatina  from  1799  to  1822,  and  regarded  it  as  a  com- 
paratively mild  affection,  until,  in  1824,  an  epidemic  of  unusual  severity 
broke  out  in  Tours,  which  proved  fatal  in  many  cases. 

In  contrast  with  the  epidemic  type  of  measles,  which  usually  ex- 
tends over  a  given  area  with  more  or  less  rapidity  and  limitation  as 
regards  time,  burning  itself  out  or  exhausting  the  favorable  conditions 
for  the  development  of  the  poison,  epidemic  scarlatina  may  show  a 
much  more  irregular  and  protracted  course,  often  covering  a  period 
of  months,  when  the  duration  of  the  epidemic  of  measles  has  been  as 
many  weeks.  This  difference  is  well  illustrated  in  the  epidemics  oc- 
curring in  the  Canary  Islands,  noted  above  (see  p.  171). 

By  some  authorities  an  attempt  has  been  made  to  establish  a  cer- 
tain periodicity  for  epidemics  of  scarlatina,  at  least,  in  given  localities; 
and,  in  many  instances,  this  periodicity  is  quite  marked,  but  with  far 
less  regularity  than  is  the  case  in  measles.  Again,  certain  groups  of 
years,  as  pointed  out  by  Hirsch,404  have  been  marked  by  wide-spread 
epidemics  of  scarlatina,  throughout  distantly  separated  countries:  a 
fact  which  would  seem  to  point  to  far-reaching  atmospheric  or  climatic 
conditions  as  in  some  way  influencing  the  spread  of  the  disease. 

DIAGNOSIS. 

The  presence  of  scarlatina  in  all  our  large  cities,  and  not  infre- 
quently throughout  the  less  closely  settled  suburban  districts,  in  a  more 
or  less  endemic  form,  associated  with  the  outbreak  of  single,  scattered, 
and  anomalous  cases,  renders  the  question  of  diagnosis  a  most  impor- 
tant one.  As  is  true  of  all  the  acute  exanthemata,  its  occurrence  in 
epidemic  form  is  invariably  of  great  help  in  determining  the  diagnosis 
of  a  doubtful  case. 

Although  in  a  typical  case  of  scarlet  fever  the  diagnosis  of  the 
infection  may  be  simple,  there  are  many  conditions  under  which  it  is 
often  extremely  difficult  to  arrive  at  a  definite  conclusion  regarding  the 
actual  nature  of  the  attack.  Particularly  is  this  true  when,  in  the  ab- 
sence of  any  epidemic  of  scarlatina,  the  case  under  observation  is  seen 
for  the  first  time  early  in  the  course  of  the  disease,  before  the  appear- 
ance of  the  characteristic  symptom-complex,  which  frequently  alone 

tot  See  Trousseau  (loc.  cit.,  p.  137). 
**  Hirsch  (loc.  cit.,  p.  129). 


SCARLATINA.  245 

justifies  one  in  determining  the  essential  character  of  the  disease  under 
consideration.  The  absolute  necessity  of  arriving  at  a  definite  conclu- 
sion at  the  earliest  possible  moment  is,  perhaps,  no  greater  in  any  of 
the  acute  exanthemata  than  in  scarlatina;  and  in  every  instance  when 
there  is  the  slightest  doubt  the  case  should  be  suspected  from  the  out- 
set, and  at  least  considered  as  scarlatina  until  the  subsequent  develop- 
ments establish  its  character  beyond  question.  In  a  small  percentage 
of  cases,  characterized  by  an  abrupt  and  overwhelming  toxaemia,  which 
prove  fatal  in  from  twenty-four  to  seventy-two  hours,  it  may  be  abso- 
lutely impossible  to  determine  the  nature  of  the  affection  during  the 
life  of  the  patient,  and  only  the  subsequent  development  of  typical 
scarlatina  in  the  same  household  clears  up  the  diagnosis  in  the  first  case. 
These  instances  are,  however,  happily  rare.  Again,  in  a  slightly  larger 
proportion,  cases  characterized  by  early  marked  involvement  of  the 
pharynx,  with  but  a  poorly  defined,  irregular,  transient,  or  wholly  ab- 
sent exanthem,  may  present  great  difficulties  in  diagnosis. 

As  Mayr  (loc.  cit.,  p.  219)  truly  says:  "The  diagnostic  signs  of  scar- 
latina are  these:  the  existence  of  a  special  efflorescence;  its  mode  of 
distribution  over  the  cutaneous  surface;  the  inflamed  state  of  the  parts 
concerned  in  deglutition;  the  peculiar  desquamation;  the  spreading 
of  the  disease  by  contagion;  its  epidemic  occurrence;  the  febrile  symp- 
toms which  accompany  it;  and,  lastly,  the  sequelae  to  which  it  gives 
rise."  With  the  existence  of  all  of  the  above  symptoms  the  diagnosis 
of  scarlet  fever  would,  indeed,  be  a  simple  matter,  but  many  of  them 
are  too  frequently  wanting,  and  one  is  hardly  prepared  to  await  the  de- 
velopment of  the  specific  sequela?,  if  such  delay  can  be  avoided,  before 
reaching  a  conclusion  as  to  the  nature  of  the  disease.  During  the  stage 
of  incubation  there  are,  as  a  rule,  no  evidences  of  the  threatened  attack, 
and  no  symptoms  characteristic  of  this  or  any  other  specific  infection. 
With  the  development  of  the  prodromal  stage  and  the  early  initial 
symptoms,  it  first  becomes  possible  to  form  an  opinion  as  to  the  nature 
of  the  attack.  Too  great  stress  cannot  be  laid  upon  the  necessity  of 
withholding,  in  all  doubtful  cases,  the  expression  of  a  positive  opinion 
for  twenty-four  hours  or  even  longer,  at  least  until  the  disease  has  de- 
clared itself  absolutely.  As  characteristic  early  symptoms  of  a  typical 
scarlatinal  infection  we  have,  during  the  first  twenty-four  hours,  the 
abrupt  onset,  associated  with  more  or  less  marked  constitutional  de- 
pression, headache,  intense  redness  and  congestion  of  the  faucial  mu- 
cous membrane,  sore  throat,  often  early  and  persistent  vomiting,  occa- 
sionally convulsions,  and  a  rapid  rise  of  temperature,  together  with  a 


246  THE    ACUTE    EXANTHEMATA. 

rapid  increase  in  the  pulse-rate.  This  sudden  onset — when  accom- 
panied by  headache,  sore  throat,  and  general  prostration — is  peculiarly 
suggestive  of  scarlatina. 

Vomiting  is  seen  at  the  beginning  both  of  pneumonia  and  small- 
pox, but  in  the  absence  of  marked  angina,  unless  accidentally  present, 
and  with  the  existence  of  other  symptoms  characteristic  of  the  two 
latter  diseases,  it  should  be  differentiated  from  that  due  to  scarlatina. 
Vomiting  of  central  origin,  due  to  the  involvement  of  the  brain  or 
meninges,  is  extremely  rare  at  the  age  of  greatest  susceptibility  to  scar- 
latina, excepting  in  cases  in  which  there  could  hardly  be  any  great 
confusion  of  symptoms.  According  to  von  Leube  (loc.  cit.,  p.  414), 
vomiting  in  scarlet  fever  is  an  initial  symptom  of  the  greatest  diag- 
nostic value,  occurring  more  often  in  this  disease  in  childhood  than  in 
any  other,  with  the  exception  of  pneumonia. 

Convulsions  in  childhood  may  also  mark  the  onset  of  measles, 
pneumonia,  diphtheria,  of  acute  cerebro-spinal  meningitis,  poliomye- 
litis, and  encephalitis;  and  in  young  children  may  be  the  result  of 
many  conditions  dependent  upon  reflex  disturbances  of  a  mild  or  severe 
type.  In  all  such  cases  one  must  await  the  development  of  other  char- 
acteristic symptoms  before  making  a  diagnosis. 

The  early  sore  throat  of  scarlatina  is  almost  as  constant  and  char- 
acteristic as  the  eruption.  Locally  there  is  present,  usually  from  the 
first,  a  diffuse,  mottled,  congested  appearance  of  the  uvula,  soft  palate, 
pharyngeal  arches,  and  even  the  tonsils,  while  the  latter  are  swollen 
and  their  follicles  prominent  and  not  uncommonly  filled  with  exudate. 
The  early  enanthem  develops,  as  a  rule,  within  the  first  twenty-four 
hours,  and  differs  essentially  from  that  seen  in  measles,  having  more 
the  character  of  a  widely  scattered  punctate  blush,  and  lacking  the 
sharply  defined,  slightly  elevated,  pin-head,  papillary  areas  of  pale, 
grayish  white, — seen  in  the  enanthem  so  characteristic  of  measles. 
Not  infrequently  the  condition  of  the  throat  closely  resembles  a  follicu- 
lar  tonsillitis,  and  in  the  absence  of  other  symptoms  an  error  in  diag- 
nosis may  easily  be  made. 

There  is  nothing  peculiarly  characteristic  in  the  early  temperature 
of  scarlet  fever.  It  rises  abruptly  with  the  onset  of  the  disease,  remain- 
ing elevated  throughout  the  febrile  period,  showing  a  slight  diurnal 
variation,  and  falling  by  lysis,  toward  the  end  of  the  first  week,  to 
normal.  Measles,  on  the  other  hand,  shows  during  the  second  and  third 
day  of  the  attack  a  decided  remission  in  the  temperature,  which  rises 
again  with  the  development  of  the  exanthem. 


SCARLATINA.  24? 

In  a  large  majority  of  cases  the  pulse-rate  increases  rapidly,  very 
commonly  out  of  all  proportion  to  the  height  of  the  fever, — a  point  to 
which  attention  has  already  been  called, — and  frequently  maintains  this 
disproportion  throughout  the  febrile  period. 

During  the  second  twenty-four  hours,  in  addition  to  the  symptoms 
noted  above,  which  usually  increases  in  severity,  the  characteristic  erup- 
tion develops,  accompanied  by  enlargement  of  the  superficial  lymphatic 
glands.  Occurring  first  upon  the  upper  thorax  and  spreading  quickly 
over  the  throat,  neck,  chest,  extremities,  and  trunk,  with  but  slight 
involvement  of  the  face,  the  exanthem  appears  as  a  diffuse  scarlet  blush, 
which,  upon  closer  inspection,  is  seen  to  be  made  up  of  minute, 
punctate,  reddened  spots,  separated  by  areas  of  pale  skin.  In  such  a 
case,  when  associated  with  the  early  symptoms  of  the  disease,  the  diag- 
nosis is  usually  not  difficult.  In  the  absence,  however,  of  one  or  more 
of  the  initial  symptoms,  the  appearance  of  an  eruption  closely  resem- 
bling that  of  scarlatina  may  give  rise  to  great  confusion,  while  an 
anomalous  development  of  the  eruption  associated  with  any  one  of  the 
early  symptoms  may  lead  to  equally  great  uncertainty. 

Erythema. — The  similarity  between  the  eruption  of  scarlatina  and 
a  simple  erythema  is  frequently  striking.  The  fleeting  character  and 
great  variability  of  the  latter,  together  with  little  or  no  fever  and  but 
slight,  if  any,  constitutional  symptoms,  and  the  absence  of  angina  and 
enlargement  of  the  lymphatic  glands  of  the  neck,  will  serve  to  dif- 
ferentiate it.  In  this  connection  it  is  to  be  noted  that  in  all  forms  of 
erythema  of  the  skin  the  mucous  membrane  of  the  palate  may  also  be 
affected.  In  all  erythemas,  upon  close  examination,  there  will  be 
noticed  an  absence  of  the  minute,  punctate,  reddened  spots  character- 
istic of  the  early  scarlatinal  exanthem. 

Drug  Eruptions.  —  Belladonna,  opium,  quinine,  and  antipyrin 
may,  in  rare  cases,  give  rise  to  an  erythematous  eruption  almost  iden- 
tical with  that  of  scarlatina:  a  condition  which  can  be  differentiated 
from  true  scarlet  fever  by  a  careful  analysis  of  the  symptoms  present, 
together  with  a  knowledge  of  the  history  of  the  case.  As  a  rule, 
the  exanthem  appears  first  on  the  face  and  neck,  spreading  grad- 
ually over  the  entire  body,  and  is  seen  most  frequently  following  the 
administration  of  quinine.  The  danger  of  confusion  lies  in  the  pres- 
ence of  more  or  less  fever  and  the  slight  constitutional  symptoms  for 
which  the  drug  has  been  given.  When  doubt  exists,  the  discontinuance 
of  the  drug  will  be  followed  by  a  disappearance  of  the  rash,  and,  as  in 
both  scarlatina  and  measles,  by  the  occurrence  of  a  branny  or  lamellar 


248  THE   ACUTE    EXANTHEMATA. 

desquamation.  Guinon405  has  reported  a  case  in  which  antipyrin  pro- 
duced a  scarlatiniform  eruption  associated  with  angina  and  intense 
fever.  As  a  rule,  the  eruption  of  antipyrin  is  a  polymorphous  ery- 
thema and  does  not  resemble  scarlatina  so  closely  as  measles.  Morel- 
Lavallee406  has  called  attention  to  a  much  rarer  occurrence,  namely: 
the  remarkable  similarity  between  the  erythema  sometimes  produced 
by  mercury  and  the  exanthem  of  scarlatina.  Ordinarily  uncomplicated 
by  fever  or  angina,  the  severe  cases  may  be  associated  with  fever  and 
even  with  desquamation  of  the  tongue,  and  are  apparently  anatomically 
identical  with  the  scarlatinal  eruption  even  as  regards  the  cutaneous 
desquamation,  making  the  diagnosis,  in  the  absence  of  the  history, 
almost  impossible. 

Chloral  is,  in  rare  instances,  followed  by  an  erythematous  eruption 
of  the  skin  simulating  the  scarlatinal  rash,  together  with  redness  of 
the  pharyngeal  mucous  membrane  and  a  rise  of  1  or  2  degrees  in  tem- 
perature. The  absence  of  the  angina,  with  the  mild  constitutional 
symptoms  and  the  history  of  the  administration  of  the  drug,  will  aid 
in  diagnosis. 

Erythema  scarlatiniforme,  which  not  infrequently  appears  sud- 
denly as  a  bright  erythematous,  punctiform  rash  closely  resembling  the 
,  eruption  of  scarlatina,  may  be  distinguished  from  the  latter  by  its 
irregularity  of  distribution,  and  by  the  fact  that  it  does  not,  as  a  rule, 
begin  in  any  given  locality,  and  is,  further,  frequently  sharply  defined 
in  certain  areas,  as  beside  the  nose.  The  constitutional  symptoms  are 
slight;  the  temperature  may  reach  100°  to  101°  F.,  but  subsides  quickly. 
The  fauces  are  reddened,  but  there  is  no  angina.  The  disappearance 
of  the  rash  may  be  followed  by  desquamation :  as  a  rule,  f urf uraceous 
in  character. 

Erythema  scarlatiniforme  desquamativum — under  which  name  the 
French  writers  have  described  a  condition  closely  resembling  the  above, 
characterized  by  a  diffuse  erythematous  rash,  slight  angina,  mild  con- 
stitutional symptoms,  and  followed  by  desquamation — may  simulate 
scarlatina,  rendering  the  diagnosis,  in  some  cases,  extremely  difficult. 
Here,  again,  the  eruption  is  frequently  limited  to  certain  areas,  which 
may  be  sharply  defined,  and  shows  a  greater  tendency  to  become  dif- 
fuse than  punctiform,  while  the  duration  of  the  rash  is  commonly  much 
longer  than  is  the  case  of  scarlatina.  In  cases  in  which  the  mucous 


«•  See  Moizard  (foe.  Cit.,  p.  153). 

**  Morel-Lavallee  (A.):  Revue  de  Med.,  1891,  xi,  pp.  449  et  seq. 


SCARLATINA.  2-19 

membranes  are  involved,  the  tongue  may  peel  and  become  smooth  and 
red,  lacking,  however,  the  characteristic  changes  seen  in  scarlet  fever. 
The  absence  of  marked  constitutional  symptoms,  of  the  "strawberry" 
tongue,  and  of  any  marked  swelling  of  the  fauces,  together  with  the 
slight  involvement  of  the  superficial  lymphatic  glands,  and  the  history 
of  similar  attacks — for  it  shows  a  marked  tendency  to  recur — will  fur- 
ther aid  in  the  diagnosis.  The  writer  has  notes  of  a  case  of  this  char- 
acter in  which  the  patient  had  repeated  attacks  in  a  certain  locality, 
and  remained  free  from  the  disease  while  residing  in  another  city  not 
more  than  thirty  miles  distant. 

In  this  connection  the  following  case  is  of  sufficient  value  to  be 
given  in  detail,  as  illustrating  the  difficulty  of  establishing  a  diagnosis 
without  reference  to  the  history,  and  further  in  proof  of  the  state- 
ment already  made  that  the  appearance  of  a  characteristic  desquama- 
tion  is  by  no  means  always  an  infallible  sign  of  recent  scarlatina407:— 

M.  D.  Aged  20.  As  a  child  she  had  measles,  chicken-pox,  and 
diphtheria.  With  the  exception  of  the  history  given  below,  her  health 
has  been  generally  good.  In  1891,  when  eleven  years  of  age,  she  went 
through  a  severe  attack  of  scarlet  fever.  Her  younger  sister,  ill  at  the 
same  time,  died  from  the  effects  of  the  infection. 

In  1894  she  had  what  was  apparently  a  typical  attack  of  erythema 
scarlatiniforme  desquamativum,  following  which  she  remained  well 
until  April,  1900,  when  she  went  through  a  similar  attack,  which  lasted 
two  weeks.  In  May  she  had  a  third  similar  illness  lasting  seven  weeks; 
and  again  on  August  26th  of  this  year  (1900)  a  fourth  attack. 

When  first  seen  on  the  second  day  of  this  last  illness,  there  was 
some  slight  rise  of  temperature,  which  lasted  but  a  day  or  two,  while 
the  pulse-rate  was  correspondingly  quickened.  The  mucous  membrane 
of  the  mouth  and  pharynx  was  congested,  showing  everywhere  a  diffuse 
redness;  the  tongue  was  coated,  the  tip  and  edges  reddened,  and  the 
eruption  typically  scarlatiniform  in  character.  A  bright  scarlet  blush 
was  well  marked  over  the  entire  body. 

The  eyes  were  congested,  reddened,  and  watery,  and  the  con- 
junctivas somewhat  inflamed;  photophobia  was  marked,  the  condition 
of  the  eyes  being  more  typical  of  the  early  catarrhal  inflammation  seen 
in  measles.  The  urine  was  negative. 

By  the  seventh  day  of  the  attack  all  the  acute  symptoms  had  sub- 


407  The  writer  wishes  to  express  his  indebtedness  to  Dr.   Corlett  for  the  privilege 
of  seeing  this  remarkable  case. 


250  THE   ACUTE    EXANTHEMATA. 

sided,  and  desquamation  was  advancing  rapidly,  the  characteristic  scaly 
flakes  being  present  on  the  trunk  and  arms,  while  on  the  feet  typical 
lamellar  desquamation  was  marked. 

Erysipelas  should  ordinarily  be  easily  differentiated  from  a  true 
scarlatinal  eruption  by  the  peculiar  character  of  its  development,  ex- 
tension, and  commonly,  its  localization.  Earely  the  occurrence  of  an 
erysipelatous  eruption  in  a  woman,  known  to  have  been  exposed  just 
previous  to  or  immediately  following  confinement,  or  in  those  the  sub- 
jects of  operative  wounds,  may  lead  to  confusion  in  diagnosis,  which 
only  subsequent  facts  can  satisfactorily  clear  up. 

The  enlargement  of  the  superficial  lymphatic  glands  during  the 
second  twenty-four  hours  of  the  attack  is,  perhaps,  of  but  slight  diag- 
nostic value,  and  yet  in  a  doubtful  case  might  well  be  of  great  sig- 
nificance. Von  Jiirgensen  (loc.  cit.,  p.  222)  emphasizes  the  diagnostic 
importance  of  early  enlargement  of  the  inguinal  glands  in  scarlet  fever. 
Schamberg  (loc.  cit.),  in  his  analysis  of  a  hundred  cases,  says:  "In  dif- 
ferentiating the  rashes  of  diphtheria  from  true  scarlatina  the  study  of 
the  glands  is,  perhaps,  of  inconsiderable  value.  A  well  marked  enlarge- 
ment of  all  the  superficial  glands,  particularly  the  epitrochlear  and 
axillarj7,  would,  in  doubtful  cases,  tend  to  throw  the  balance  in  favor 
of  scarlet  fever."  Further:  "In  distinguishing  between  scarlatina  and 
measles  an  examination  of  the  glands  lends  but  little  aid,  .  .  . 
it  is  to  be  noted,  however,  that  the  adenopathy  of  measles  is  not  nearly 
as  well  marked  as  that  observed  in  scarlet  fever."  As  an  aid  in  dis- 
tinguishing between  the  scarlatiniform  erythemata,  in  which  there  is 
but  slight  glandular  involvement,  and  true  scarlatina,  the  enlargement 
of  the  lymphatic  glands  in  the  latter  may,  however,  be  of  real  value. 

From  the  third  to  the  sixth  day,  and  occasionally  earlier,  those 
changes  in  the  tongue — which,  in  association  with  other  constitutional 
symptoms,  are  so  peculiarly  characteristic  of  scarlet  fever — are  usually 
well  marked.  Certain  rare  conditions  of  a  chronic  character  may  more 
or  less  closely  simulate  the  "strawberry  tongue"  of  scarlatina,  but  the 
absence  of  all  other  symptoms  renders  the  diagnosis  easy.  The  early 
injection  and  enlargement  of  the  papilla?  at  the  tip  and  edges  of  the 
tongue  is  peculiarly  characteristic  of  scarlatina,  and  frequently  of  great 
diagnostic  value.  Among  the  acute  exanthemata  the  differential  diag- 
nosis between  scarlatina  and  measles,  or  scarlatina  and  German  mea- 
sles, often  presents  many  difficulties,  and,  in  the  absence  of  other  gen- 
eral symptoms,  when  the  exanthem  alone  must  largely  determine  the 
diagnosis,  great  confusion  may  arise. 


SCARLATINA.  251 

In  cases  characterized  by  an  irregular,  patchy  eruption  upon  the 
extremities  and  elsewhere,  or  when  the  rash  is,  as  rarely  happens,  of 
a  roseolar,  confluent  type,  it  may  suggest  strongly,  at  first  glance,  the 
eruption  of  measles.  In  these  cases  one  must  await  further  develop- 
ments before  expressing  an  opinion. 

Measles. — The  chief  points  of  difference  between  scarlatina  and 
measles  may  be  found  under  "Measles,"  p.  321,  also  in  table  at  the  end 
of  the  volume. 

Rubella,  or  German  Measles. — While  rubella  is,  perhaps,  more  fre- 
quently confused  with  measles  than  with  any  other  affection,  in  cer- 
tain cases  characterized  by  an  irregular  or  roseolar  eruption  confusion 
in  diagnosis  may  arise.  The  differential  diagnosis  between  scarlet  fever 
and  rubella  will  be  found  fully  considered  under  the  latter  disease  (see 
page  369). 

Small-pox. — The  early  rash  preceding  the  formation  of.  the  pust- 
ules in  small-pox  may  bear  a  striking  resemblance  to  the  eruption  of 
scarlet  fever,  a  full  discussion  of  which  will  be  found  under  "Variola" 
(see  page  89). 

Diphtheria.  —  The  differential  diagnosis  between  scarlatina  and 
diphtheria  may,  in  certain  cases,  present  great  difficulty,  the  occurrence 
of  the  false  membrane  in  the  pharynx,  and  the  not  infrequently  coin- 
cident development  of  a  transient  toxic  erythema  in  diphtheria  closely 
resembling  conditions  seen  in  scarlet  fever.  Fortunately,  in  doubt- 
ful cases  early  and  prompt  isolation  would  in  either  case  be  insisted 
upon.  In  a  small  percentage  of  cases  scarlatina  may  develop  under 
conditions  which  have  admitted  previous  exposure  to  diphtheria,  and 
a  diphtheria  may  be  present  complicating  early  scarlet  fever.  It  is  an 
interesting  clinical  fact  that,  when  diphtheria  is  the  secondary  invader, 
this  complication  occurs  more  often  late  in  the  course  of  the  disease, 
after  the  disappearance  of  the  scarlatinal  angina;  when,  however,  scar- 
let fever  is  the  secondary  invader,  it  is  perhaps  more  frequently  seen 
early  in  the  attack  of  diphtheria.  Cases  characterized  by  the  presence 
of  other  micro-organisms,  as  the  streptococcus  pyogenes,  are  examples 
of  so-called  mixed  infection,  and  such  is  the  condition  commonly  seen 
in  the  early  scarlatinal  anginas  complicated  by  diphtheria,  as  well  as 
often  in  diphtheria  occurring  late  in  the  attack. 

As  a  rule,  the  onset  in  diphtheria  is  much  less  abrupt,  and  the  con- 
stitutional depression  frequently  more  pronounced  than  in  scarlatina, 
the  actual  attack  being  preceded  by  a  period  of  two  or  three  days 
during  which  the  patient  complains  of  vague  pains  in  the  back  and 


252  THE   ACUTE    EXANTHEMATA. 

limbs,  or  slight  chilly  sensations.  In  scarlatina  the  violent  onset  and 
pronounced  initial  symptoms  are  commonly  the  first  indications  of 
the  threatened  infection.  In  young  children  convulsions  may  mark  the 
onset  of  both  diphtheria  and  scarlatina.  The  mucous  membrane  of 
the  pharynx,  early  in  the  course  of  diphtheria,  is  congested  and  red- 
dened, lacking,  however,  the  characteristic  mottling  of  the  scarlatinal 
enanthem.  Upon  this  point,  however,  too  great  reliance  must  not  be 
placed.  Difficulty  and  pain  on  swallowing  may  be  present  as  in  scar- 
latina. 

The  early  appearance  of  the  false  membrane  upon  the  tonsils, 
usually  on  the  first  or  second  day  in  diphtheria,  and  its  late  develop- 
ment in  the  severe  diphtheroid  angina  of  scarlet  fever  are  points  of 
great  diagnostic  value.  Finally  there  is  less  tendency  to  invasion  of  the 
larynx  in  the  streptococcic  scarlatinal  angina  than  in  diphtheria. 

In  those  cases  of  diphtheria  in  which  there  is  no  manifestation  of 
a  local  membrane,  but  which  present  a  simple  catarrhal  angina,  the 
diagnosis  as  between  diphtheria  and  a  mild  scarlatina  without  exan- 
them  may  be  impossible  without  bacteriological  proof  of  the  presence 
of  the  Klebs-Loeffler  bacillus. 

When,  in  addition  to  the  general  and  local  pharyngeal  symptoms, 
a  diffuse,  dark  or  lighter  scarlet  erythema  appears  upon  the  trunk, 
extending  rapidly  over  a  more  or  less  limited  area,  frequently  fading 
where  first  seen,  as  it  advances,  or  disappearing  only  to  reappear  again, 
the  diagnosis  may  be  unusually  difficult.  In  these  instances  the  color 
of  the  eruption,  which  is  frequently  darker  than  the  scarlatinal  rash; 
its  situation,  subsequent  development,  and  irregular  distribution,  and 
its  fleeting  nature;  together  with  the  absence  of  the  punctiform  char- 
acter seen  in  scarlatina,  and  of  desquamation,  serve  to  distinguish  it 
from  the  latter  disease.  Finally,  the  far  greater  liability  to  the  occur- 
rence of  paralyses  following  true  diphtheria,  and  the  much  greater 
frequency  of  marked  renal  involvement  in  scarlatina,  are  of  value  in 
determining  between  the  two  diseases.  While  in  doubtful  cases,  seen 
early  in  their  course,  great  confusion  may  arise,  the  bacteriological  ex- 
amination— when  available — must  always  remain  our  ultimate  proof. 
Osier  says  (loc.  cit.,  p.  78):  "Scarlet  fever  and  diphtheria  may  co-exist; 
but  in  a  case  presenting  wide-spread  erythema  and  extensive  mem- 
branous angina,  with  Loeffler's  bacillus,  it  would  puzzle  Hippocrates  to 
say  whether  the  two  diseases  co-existed  or  whether  it  was  only  an  in- 
tense scarlatinal  rash  in  diphtheria." 

Tonsillitis. — The  diagnosis  of  scarlatina,  from  an  attack  of  acute 


SCARLATINA.  253 

follicular  tonsillitis  is  often  difficult,  and  may  even  be  impossible. 
Slight  subjective  symptoms  usually  precede  the  pharyngeal  inflam- 
mation; but  these  may  be  wanting  and  the  resemblance,  in  many 
instances,  to  the  onset  of  scarlet  fever  may  be  striking.  Vomiting  is, 
however,  rarely  present.  The  temperature  rises  rapidly,  frequently 
touching  a  higher  point  than  is  seen  early  in  the  latter  disease,  while 
the  constitutional  depression  may  be  extreme.  The  pulse  is  rapid,  but 
does  not  show  any  pronounced  disproportion  to  the  fever.  The  early 
appearance  of  the  pharyngeal  mucous  membrane  is  frequently  iden- 
tical with  that  observed  in  scarlet  fever.  The  tonsils  are  reddened  and 
swollen,  with  foci  of  exudate  in  the  crypts;  the  tongue  is  coated,  and 
swallowing  is  painful.  Slight  swelling  of  the  cervical  lymphatic  glands 
may  be  present,  but  does  not,  as  a  rule,  reach  the  same  degree  found 
in  scarlatina,  and  at  this  time  the  two  conditions  may  show  a  striking 
similarity.  The  absence  of  vomiting,  of  convulsions,  and  of  severe 
headache  are  of  purely  negative  value  as  -an  aid  in  diagnosis,  while  the 
temperature  and  the  constitutional  depression,  frequently  more  marked 
in  tonsillitis  than  in  scarlatina,  are  of  equally  slight  value  in  deter- 
mining between  the  two  diseases.  It  is,  indeed,  often  only  possible  to 
distinguish  between  them  with  the  appearance  of  the  true  scarlatinal 
exanthem.  The  occurrence  of  a  simple  erythema  in  tonsillitis  may 
still  further  lead  to  confusion;  but  in  these  cases  its  limitation  to 
the  chest  or  to  the  neck,  the  absence  of  -any  punctiform  character, 
its  short  duration,  and  the  absence  of  desquamation  would  determine 
its  nature. 

The  tongue  remains  coated  throughout  the  course  of  the  attack, 
the  early  injection  and  prominence  of  the  papillge  is  wanting,  and  the 
characteristic  changes  seen  in  scarlatina  do  not  take  place. 

Influenza. — During  the  occurrence  of  influenza  in  epidemic  form, 
and  in  the  absence  of  any  marked  prevalence  of  scarlet  fever,  there  is, 
ordinarily,  little  or  no  difficulty  in  distinguishing  between  the  two  con- 
ditions. In  certain  instances,  however,  under  circumstances  which 
favor  the  existence  of  both  diseases,  more  or  less  confusion  may  readily 
arise.  It  is  not  wholly  surprising  that  a  disease  which  manifests  itself 
in  varying  epidemics,  and  in  single  cases  with  such  a  shifting  symp- 
tomatology, should,  in  exceptional  cases,  simulate  in  one  way  or  another 
a  true  scarlatinal  infection.  Though  the  early  constitutional  symptoms 
of  influenza  are  peculiarly  characteristic,  they  may  be  absent,  and  in 
those  cases  characterized  by  a  bright  scarlatiniform  rash  associated  with 
fever  and  prostration,  even  in  the  absence  of  any  angina,  the  question 


254  THE   ACUTE    EXANTHEMATA. 

of  diagnosis  may  be  a  difficult  one,  the  symptoms  present  being  those 
of  a  mild  or  anomalous  attack  of  scarlet  fever. 

The  characteristic  changes  in  the  tongue  are,  however,  not  seen, 
and  frequently  the  early  development  of  some  one  of  the  many  com- 
plications of  influenza,  as  bronchitis  or  pneumonia,  determines  the 
specific  nature  of  the  infection. 

Cerebro-spinal  Meningitis.  —  Acute  cerebro-spinal  meningitis — 
owing  to  the  convulsions,  sore  throat,  and  eruption  which  may  accom- 
pany it — is  occasionally  confused  with  scarlatina.  The  character  of  the 
onset  and  of  the  eruption — very  unlike  that  in  scarlet  fever — and  the 
early  symptoms  referable  to  the  neck  are,  however,  of  great  value  as 
aids  in  differentiation. 

The  diagnosis  of  scarlet  fever  in  the  negro  is  often  extremely  diffi- 
cult; and  one  is  forced  to  rely,  early  in  the  attack,  more  upon  the 
nature  of  the  enanthem  than  upon  the  appearance  of  an  eruption  in 
any  way  characteristic  of  the  disease.  When  fully  developed,  the  rash 
may,  as  a  rule,  be  readily  detected,  lacking,  however,  the  distinct  scar- 
let hue,  #nd,  as  would  be  expected,  being  most  pronounced  in  those 
localities  where  the  pigmentation  of  the  skin  is  less  dark.  Desquama- 
tion  follows,  and  the  general  symptomatology  differs  in  no  way  from 
that  seen  in  the  white  race. 

PROGNOSIS. 

In  no  disease  is  the  prognosis  more  uncertain  than  in  scarlet  fever, 
it  being  impossible  to  determine  in  any  instance  from  the  character 
of  the  initial  symptoms  what  the  ultimate  result  may  be. 

While  it  is  true  that  the  malignancy  of  different  epidemics  varies 
greatly,  and  the  total  percentage  of  mortality  following  successive 
outbreaks  of  scarlatina  shows  a  wide  range,  yet  the  prevalence  of  an  un- 
usually mild  epidemic  type  does  not  justify  one  in  reaching  a  conclu- 
sion as  to  the  character  of  single  cases.  Here,  as  elsewhere,  many 
conditions  enter  into  and  influence  the  subsequent  development  of  the 
infection,  rendered  all  the  more  uncertain  by  the  striking  variability  in 
the  virulence  of  the  scarlatinal  poison. 

Although  the  prognosis  in  a  given  epidemic,  taken  as  a  whole,  may 
be  good  or  bad,  it  can  in  any  event  modify  but  slightly  that  of  the 
individual  case.  Thomas  (loc.  cit.,  p.  291)  considers  an  epidemic  in 
which  the  mortality  is  below  10  per  cent,  as,  comparatively  speaking, 
of  a  benign  character.  Johannessen  (loc.  cit.,  p.  138)  found  the  average 
percentage  of  mortality  in  Norway  for  twelve  years  between  1867  and 


SCARLATINA.  255 

1878  to  be  12.7  per  cent.  Hirsch  (loc.  cit.)  gives  the  mortality  in  scar- 
let fever  as  ranging  from  3  to  30  per  cent.  In  McCollom's  series  of  a 
thousand  cases  the  mortality  was  9.8  per  cent.,  and,  according  to  this 
observer  (loc.  cit.),  the  morbidity  for  the  city  of  Boston  in  1898  was 
16.77  per  cent.  Exceptionally  the  mortality  may  reach  40  per  cent. 

Among  those  circumstances  which  very  largely  affect  the  mor- 
tality in  individual  instances,  and  thus  influence  the  prognosis,  social 
condition  plays  an  important  part.  Though  it  has  been  shown  that  in 
degree  of  susceptibility  to  the  scarlatinal  poison  social  position  makes 
little  or  no  difference,  the  difficulty  of  proper  isolation  and  treatment, 
and,  too,  often  the  utter  lack  of  that  reserve  vitality  in  the  children  of 
the  poor  add  greatly  to  the  danger  of  mortality.  In  a  certain  measure, 
this  is  offset  in  the  upper  classes  by  the  occurrence  of  that  striking 
family  and  individual  idiosyncrasy  which  we  have  no  means  of  fore- 
telling or  avoiding,  and  as  a  result  of  which  whole  families  or  indi- 
vidual members  of  a  given  household  may  show  an  unusual  reaction  to 
the  specific  contagion  during  a  supposedly  mild  epidemic,  even  suc- 
cumbing to  the  disease,  while  others  in  the  same  family  escape  with 
but  a  light  attack,  or  even  altogether. 

Age  affects  the  prognosis  in  general,  directly,  the  mortality  being 
greatest  in  children  under  six  years  of  age.  Below  one  year  the  mor- 
tality, as  given  by  Johannessen  (loc.  cit.,  p.  146)  for  the  twelve  years 
noted  above,  was  10.3  per  cent.  The  development  of  scarlatina,  on  the 
other  hand,  in  an  adult  not  infrequently  means  a  pronounced  suscepti- 
bility on  the  part  of  the  individual  attacked,  and  the  prognosis  should 
be  always  extremely  guarded. 

Sex  has  little  or  no  effect  upon  the  ultimate  outcome,  except  as  it 
may  imply  a  more  robust  vitality,  which  too  often  avails  nothing. 

With  the  occurrence  of  scarlatina  during  pregnancy  or  in  the 
puerperium,  in  individuals  the  subjects  of  surgical  or  accidental  wounds, 
as  well  as  in  the  weak  and  enfeebled,  the  prognosis  is  grave. 

Among  those  conditions  which  may  directly  affect  the  prognosis 
early  in  the  course  of  the  attack,  the  following  symptoms  are  unfavor- 
able: Hyperpyrexia ;  an  extremely  rapid,  feeble,  or  irregular  pulse; 
great  dyspnoea  and  threatened  collapse;  persistent  vomiting  and  diar- 
rhea; pronounced  cerebral  disturbance,  delirium,  stupor,  or  convul- 
sions. An  irregular,  anomalous,  or  poorly  developed  rash,  if  intense, 
suggests  extreme  virulence.  In  mild  cases  the  rash  may  be  irregular, 
and  poorly  developed,  but  it  is  fainter,  more  evanescent,  and  .usually 
associated  with  mild  constitutional  symptoms. 


256  THE   ACUTE    EXANTHEMATA. 

Later  the  development  of  severe  pharyngeal  inflammation  and 
ulcerative,  or  membranous,  angina,  makes  the  prognosis  more  doubtful, 
while  the  occurrence  at  any  period  during  the  course  of  the  disease, 
of  one  or  more  of  the  recognized  complications  brings  at  once  an 
additional  element  of  uncertainty  as  to  the  ultimate  result  of  the 
attack. 

Among  complications  most  to  be  dreaded  as  affecting  the  prog- 
nosis are  the  development  of  diphtheria  or  broncho-pneumonia, 
marked  involvement  of  the  heart,  and  nephritis,  with  the  added  danger 
of  uraemia,  while  the  presence  of  a  general  septic  infection  is  of  the 
gravest  significance. 

In  conclusion,  it  may  be  said  that  in  no  case  of  scarlatina,  no 
matter  how  mild  its  onset,  should  one  venture  to  express  a  definite 
opinion  as  to  the  course  of  the  attack;  nor  even  after  the  subsidence  of 
the  acute  stage  should  one  be  any  less  guarded  in  affirming  its  final 
outcome,  for  here,  far  more  than  in  any  of  the  other  acute  exan- 
themata, there  lurks  an  element  of  danger,  which,  appearing  suddenly 
and  unlocked  for,  may  alter  in  a  few  hours  the  entire  course  of  events, 
even  after  convalescence  has  been  apparently  well  established. 

TREATMENT. 

In  the  management  of  scarlatina,  the  fact  that  we  know  so  little 
of  the  essential  nature  of  the  specific  virus;  that  we  have  no  single 
rational  line  of  treatment,  based  upon  etiological  proof;  and  that  it 
is  often,  in  a  given  instance,  absolutely  impossible  to  determine  when 
or  where  exposure  occurred,  or  to  predict  in  any  individual  case  the 
degree  of  susceptibility  to  the  infection,  add  much  to  the  difficulty  in 
the  control  of  the  disease. 

In  any  consideration  of  the  treatment  of  scarlatina  prophylaxis 
becomes  at  once  the  first  and  most  important  measure  in  limiting  the 
spread  of  the  contagion.  With  the  development  of  the  actual  attack, 
the  management  of  the  disease  itself  and  of  the  individual  symptoms 
as  they  arise  assumes  the  chief  role,  while,  finally,  the  occurrence  of 
any  one  of  the  many  complications  constitutes  the  third  stage  in  treat- 
ment. The  importance  of  all  measures  for  the  limitation  of  contagion 
is,  of  course,  obvious. 

Prophylaxis. — It  has  been  clearly  demonstrated,  in  the  manage- 
ment of  all  acute  infectious  and  highly  contagious  diseases,  that  the 
prompt  segregation  and  isolation  of  patients  is  the  safest  and  only 
method  of  limiting  the  further  spread  of  the  infection;  and  to  no  one 


SCAELATINA.  257 

of  the  acute  exanthemata  does  this  apply  more  truly  than  to  scarlatina. 
While  there  may  be  a  wide  difference  of  opinion  as  to  the  contagious- 
ness of  the  disease  during  the  .early  stages  of  its  development,  experi- 
ence has  repeatedly  shown,  both  in  hospital  and  private  practice,  that 
immediate  isolation  of  the  suspected  case  renders  the  danger  of  sub- 
sequent contagion  far  less  than  in  the  case  of  measles.  That  this  is 
due  in  a  very  large  measure  to  the  weak  powers  of  diffusibility  and 
the  difficulty  of  aerial  infection  by  the  scarlatinal  virus  seems,  to  the 
writer,  highly  probable.  In  all  cities  where  the  danger  of  the  occur- 
rence and  spread  of  scarlatina  is  naturally  greatest,  the  only  safe  and 
adequate  method  of  controlling  the  disease  is  the  establishment  of  hos- 
pitals, or  properly  equipped  pavilions  in  connection  with  established 
hospitals,  where  such  cases  may  be  received  and  cared  for,  thereby 
greatly  lessening  the  danger  of  its  occurrence  in  an  epidemic  form.  In 
this  way  only  is  it  possible  to  limit  materially  the  prevalence  of  scar- 
latina in  any  locality,  and  that  such  can  be  accomplished  is  proved  by 
the  fact  that  in  one  of  our  largest  cities408  scarlet  fever  has  actually 
diminished  in  frequency,  during  the  last  three  years,  owing  to  the  use 
of  an  isolation  hospital  large  enough  to  receive  all  applicants  for  ad- 
mission. Although,  with  the  single  exception  of  variola,  no  one  of  the 
acute  exanthemata  is  dreaded  in  quite  the  same  way  by  the  public  at 
large,  who  have,  in  many  instances,  learned  through  bitter  experience 
to  appreciate  the  uncertainty  which  lurks  in  every  case  of  scarlet  fever, 
it  is  constantly  surprising  to  see  the  reluctance  with  which  even  the 
educated  classes  give  their  support  to  sanitary  measures  of  this  kind. 
One  great  danger  in  the  management  of  scarlatina  naturally  arises 
from  the  fact  that  there  are,  as  a  rule,  no  warnings  of  the  coming  at- 
tack. It  repeatedly  happens  that  children  play  about,  apparently  per- 
fectly well  up  to  within  a  few  hours  of  the  appearance  of  the  initial 
symptoms,  affording  every  opportunity  for  contagion  and  almost  limit- 
less extension  of  the  disease.  That  this  does  not  follow  more  frequently 
renders  the  danger  no  less,  the  one  striking  peculiarity  of  the  disease 
being  its  uncertain  character.  In  controlling  the  spread  of  scarlet 
fever  all  efforts  on  the  part  of  the  physician  may  be  of  little  avail  with- 
out the  intelligent  and  hearty  co-operation  of  the  general  public,  and 
in  furtherance  of  this  the  establishment  of  local  boards  of  health  for 
the  proper  surveillance  of  all  cases  arising  in  their  territory,  and  for 
the  publication  of  such  advice  as  may  be  best,  giving  intelligently  and 


See  McCollom  (loc.  cit.). 


258  THE    ACUTE    EXANTHEMATA. 

plainly  the  simple  hygienic  facts  for  the  prevention  of  scarlatina,  is  of 
the  greatest  aid.  Such  a  bulletin  published  by  the  Michigan  State 
Board  of  Health,  March,  1900,  for  free  distribution  includes  the  fol- 
lowing:— 

"HOW    TO    AVOID   AND   PREVENT    SCARLET    FEVER." 

(.4)  "Avoid  the  special  contagium  of  the  disease.  It  is  especially 
important  that  this  should  be  observed  by  children  and  all  whose 
throats  are  sore  from  any  cause.  Children  under  ten  years  of  age  are 
in  much  greater  danger  of  death  from  scarlet  fever  than  are  adults; 
but  adult  persons  often  contract  and  spread  the  disease,  and  sometimes 
die  from  it.  Mild  cases  in  adults  may  thus  cause  fatal  cases  among  chil- 
dren. Because  of  these  facts  it  is  frequently  dangerous  for  children  to 
go  where  adult  persons  go  with  almost  perfect  safety  to  themselves." 

(B)  "Do  not  let  a  child  go  near  a  case  of  scarlet  fever.    Do  not 
permit  any  person  or  any  animal  to  come,  or  anything  to  be  brought, 
directly  from  a  case  of  scarlet  fever  to  a  child.    Unless  your  services 
are  needed,  keep  away  from  the  disease  yourself.    If  you  do  visit  a  case, 
bathe  yourself  and  change  and  disinfect  your  clothing  before  you  go 
where  there  is  a  child." 

(C)  "The  contagium  of  scarlet  fever  may  retain  its  virulence  for 
some  time,  and  be  carried  a  long  distance  in  various  substances  and 
articles  in  which  it  may  have  found  lodgment.    Do  not  permit  a  child 
to  enter  a  privy  or  water-closet,  or  breathe  the  air  from  a  privy,  water- 
closet,  cess-pool,  or  sewer,  into  which  non-disinfected  discharges  from 
persons  sick  with  scarlet  fever  have  entered,  nor  to  drink  water  or  milk 
which  has  been  exposed  to  such  air." 

(D)  "Do  not  permit  a  child  to  ride  in  a  closed  carriage  in  which 
there  has  been  a  person  sick  with  scarlet  fever,  unless  the  carriage  has 
since  been  thoroughly  disinfected  with  fumes  of  burning  sulphur,  etc." 

(E)  "During  the  prevalence  of  scarlet  fever  in  epidemic  form, 
avoid  exposure  to  wind  and  to  breathing  cold,  dry  air;  also  the  use  of 
strong  vinegar  or  any  other  substance  which  tends  to  make  the  throat 
raw  and  tender." 

(F}  "Do  not  wear  or  handle  clothing  worn  by  persons  during  their 
sickness  or  convalescence  from  scarlet  fever." 

(G)  "Beware  of  any  person  who  has  a  sore  throat.  Do  not  kiss 
such  a  person.  Do  not  drink  from  the  same  cup,  nor  use  any  article 
that  has  been  used  by  a  person  sick  with  this  disease." 

(//)  "Beware  of  crowded  assemblies  in  unventilated  rooms." 


SCARLATINA.  259 

(/)  "Do  not  permit  a  child  to  drink  water  or  take  food  which 
comes  from  a  source  that  renders  it  liable  to  contain  something  derived 
from  a  person  sick  with  scarlet  fever." 

In  Ohio,  as  in  most  States,  the  law  requires  the  attending  phy- 
sician to  report  the  occurrence  of  any  contagious  disease,  within  twelve 
hours  after  the  diagnosis  is  certain,  to  the  board  of  health  having 
jurisdiction  over  the  territory  in  which  such  case  is  found.  That  all 
too  frequently  the  lapse  of  time  necessary  to  determine  the  specific 
nature  of  the  attack  admits  of  wide-spread  exposure  and  contagion  is 
the  experience  of  every  physician,  and  one  can  but  emphasize  again 
and  again,  with  this  fact  in  mind,  the  absolute  necessity  of  treating 
every  doubtful  case  as  one  of  scarlatina.  This  is  particularly  appli- 
cable to  those  cases  characterized  by  mild  throat  symptoms,  or,  as  fre- 
quently happens,  by  the  appearance  of  the  eruption  first  upon  the 
small  of  the  back,  as  a  transient  efflorescence,  associated  with  but  slight 
constitutional  symptoms, — a  mild  scarlatina, — but  one  capable  of  giv- 
ing rise  to  the  most  severe  type  of  the  disease  in  a  susceptible  indi- 
vidual. In  such  cases,  as  has  happened  more  than  once  to  the  writer, 
the  attending  physician,  uncertain  throughout  the  entire  course  of  the 
attack  as  to  its  exact  nature,  may  be  regarded  as  "finnicky"  and  unjust, 
or  his  ability  may  be  even  for  the  moment  questioned,  until  the  ap- 
pearance of  typical  desquamation  absolutely  confirms  the  diagnosis. 
It  is  almost  certain  that  in  these  cases  close  quarantine  will  be  heartily 
resented;  but  who  can  say  what  might  not  be  the  result  were  isolation 
not  strictly  enforced?  In  every  case  the  responsibility  of  preventing 
any  further  spread  of  the  contagion  rests  upon  the  attending  phy- 
sician. His  duty  to  the  community,  to  the  family  directly  concerned, 
and  to  the  patient,  as  well  as  to  himself,  demands  that  every  precaution 
be  taken  to  limit  the  spread  of  the  disease. 

With  the  development  of  symptoms  in  any  way  suggestive  of  scar- 
latina in  a  child  or  adult,  the  patient  should  be  quarantined  at  once, 
shut  off  from  communication  with  all  but  one  or,  at  the  most,  two 
individuals  (the  child's  mother  and  nurse),  and  carefully  watched  until 
a  positive  diagnosis  can  be  made. 

The  diagnosis  being  certain,  and,  indeed,  in  all  cases  which  con- 
tinue doubtful  for  twenty-four  hours,  isolation  should  be  rigorously 
enforced  and  continued  until  all  possible  danger  of  contagion  is  past. 
On  the  average,  this  may  be  said  to  cover  a  period  of  from  six  to  eight 
weeks,  and  not  infrequently  longer.  For  this  purpose  a  room  should 
be  chosen  preferably  at  the  top  of  the  house,  with,  if  possible,  two  win- 


260  THE   ACUTE    EXANTHEMATA. 

dows  having  a  southern  exposure  and  an  open  fire-place.  Where  avail- 
able, the  use  of  two  rooms  with  a  communicating  door,  or  with  doors 
closely  adjoining  on  a  common  hall,  is  of  the  greatest  advantage.  This 
room  should  be  stripped  of  all  furnishings,  excepting,  of  course,  such 
articles  as  are  essential  to  the  proper  comfort  and  care  of  the  patient 
or  of  actual  necessity  to  the  nurse.  The  carpet  should  be  taken  up,  old 
pieces  of  carpet,  which  can  be  destroyed  later,  being  put  down  in  its 
place;  drapery  and  curtains  must  be  removed;  pictures,  books,  and 
all  ornaments  taken  out;  closets  emptied;  and,  in  short,  nothing 
allowed  to  remain  in  the  room  which  is  not  absolutely  necessary  for 
the  proper  conduct  of  the  case,  and  which  could  possibly  harbor  the 
specific  poison.  The  bedstead  should  preferably  be  of  iron,  with  a 
woven  wire  mattress,  the  so-called  hospital  bed  being  the  most  advan- 
tageous, permitting  the  easy  handling  and  care  of  the  patient.  The 
upper  mattress  should  be  of  horse-hair,  and  of  the  common  thickness; 
if  too  thin  it  is  apt  to  become  hard  and  uncomfortable.  The  bedding 
should  be  light,  but  of  sufficient  warmth,  and  only  such  should  be  used 
as  can  subsequently  be  boiled  or  destroyed.  A  flannel  night-gown 
should  be  worn  throughout  the  course  of  the  disease.  Handkerchiefs 
may  be  used  when  they  can  be  destroyed.  If  this  is  not  possible,  gauze 
or  old  linen,  cut  into  the  required  size,  may  be  substituted,  and,  after 
being  used,  should  be  immediately  burned.  The  sick-room  should  be 
further  provided  with  a  special  set  of  dishes  and  utensils  for  the  pa- 
tient's use,  which  should  not  be  allowed  to  go  outside.  A  small  gas- 
stove  or  kerosene-lamp  shoulfl.  be  added  for  the  purpose  of  procuring 
boiling  water,  or  for  the  actual  preparation  in  the  sick-room  of  such 
food  as  may  be  necessary. 

The  nurse  in  charge  of  the  case  should  wear  a  uniform  which  can 
be  thoroughly  boiled,  and  should  always,  when  in  the  sick-room,  keep 
her  hair  covered  by  a  suitable  cap.  Under  no  circumstances  should  she 
be  allowed  to  come  into  contact,  either  direct  or  indirect,  with  the 
other  members  of  the  family. 

The  physician  in  daily  attendance  should  put  on  a  linen  duster, 
or  other  special  gown,  before  entering  the  sick-room,  and  still  further 
protect  his  head  by  a  skull-cap,  and  should  come  into  actual  contact 
with  the  patient,  as  little  as  possible.  Before  leaving,  he  must  thor- 
oughly wash  and  disinfect  his  hands,  spraying  his  hair,  beard,  and 
clothing  with  a  10-per-cent.  solution  of  formalin.  He  should  return 
to  the  open  air  as  quickly  as  possible,  and  remain  out-of-doors  for  an 
hour  or  more  before  seeing  other  children.  That  the  contagion  has 


SCARLATINA.  261 

not  infrequently  been  carried  by  a  physician  from  house  to  house  is 
well  known,  and  that  every  means  should  be  taken  to  prevent  such  an 
unhappy  occurrence  has  been  already  insisted  upon.  That  the  danger 
is  manifestly  less  when  a  complete  change  of  clothing  has  been  made 
must  be  admitted,  but  whether  this  can  be  carried  out  in  every  instance 
depends  largely  upon  individual  circumstances,  and  must  be  left  to  the 
physician  to  decide.  That  it  is  the  safest  method  to  prevent  contagion 
is  beyond  dispute.  Whenever  there  are  children  in  the  household  they 
should,  when  possible,  be  sent  away  at  once,  and  isolated  until  all 
danger  of  their  carrying  the  poison  is  past.  In  any  event  they  must 
be  taken  out  of  school  at  once,  and  kept  out  until  sufficient  time  has 
elapsed  to  justify  their,  safe  return.  The  question  as  to  whether  the 
schools  shall  be  closed  during  the  prevalence  of  an  epidemic  of  scar- 
latina is  one  of  no  little  importance,  and  must  be  decided  largely  by 
the  extent  and  severity  of  the  prevailing  epidemic.  The  method  at 
present  in  vogue  in  so  many  of  our  large  cities,  of  a  regular  inspection 
of  the  schools  and  school-children  by  specially  detailed  physicians,  as- 
sures to  the  public  the  greatest  degree  of  protection  possible  under  the 
circumstances,  and  should  in  time  show  decided  results  in  the  lessening 
frequency  of  many  contagious  diseases. 

With  scarlet  fever  in  a  household,  the  adult  members  of  the  family 
should  avoid  society,  and  under  no  circumstances  should  the  entrance 
of  children  into  the  house  be  allowed. 

Personal  Hygiene. — In  the  care  of  every  case  of  scarlatina,  no 
matter  of  how  mild  a  type,  the  secretions  from  the  nose  should  be 
removed  by  old  linen  or  gauze  handkerchiefs,  which  must  be  imme- 
diately burned;  while  the  discharges  from  the  throat  and  mouth,  which 
in  mild  cases  may  be  got 'rid  of  in  the  same  way,  should,  in  the  severer 
forms,  be  received  directly  into  a  sputum-cup  containing  a  strong  dis- 
infectant solution,  such  as  carbolic  acid,  1  to  40  in  water  (3  drachms 
to  a  pint)  or  a  solution  of  chloride  of  lime  of  the  strength  of  4  ounces 
of  the  fresh  chloride  to  a  gallon  of  water.  The  faeces  and  urine  should 
be  disinfected  by  the  chloride-of-lime  solution  or  by  strong  carbolic- 
acid  solution  (6  ounces  dissolved  in  1  gallon  of  water),  and,  in  the 
absence  of  sewer  connection,  should  be  buried  at  least  one  hundred  feet 
from  any  well  or  running  stream.  When  sewer  connections  are  avail- 
able, the  urine  and  faeces  may,  after  thorough  disinfection,  be  emptied 
into  the  closet,  which,  in  turn,  should  be  thoroughly  disinfected  and 
flushed.  All  discharges  from  the  ears  should  be  received  on  soft  pieces 
of  cloth  or  gauze  and  at  once  destroyed. 


262  THE    ACUTE    EXANTHEMATA. 

All  linen,  towels,  bedding,  etc.,  should  be  thoroughly  disinfected 
before  taken  out  of  the  room,  being  at  once  placed,  upon  removal  from 
the  patient,  in  a  solution  of  lime,  prepared  by  diluting  any  given 
amount  of  the  above  solution  with  ten  times  the  amount  of  water.  If 
preferable,  a  solution  of  sulphate  of  zinc,  4  ounces;  common  salt,  2 
ounces;  and  water,  1  gallon,  may  be  substituted  for  the  solution  of 
lime;  or  the  carbolic  acid  may  be  used.  All  linen  should  be  left  in  the 
disinfectant  solution  at  least  two  hours,  and  when  finally  taken  from 
the  sick-room  should  be  boiled  at  once,  and  laundered  separately. 

A  special  set  of  dishes,  glasses,  and  utensils  should  remain  in  the 
patient's  room,  but,  if  removed,  should  be  placed  first  in  the  disinfectant 
solution  and  then  be  immediately  boiled.  All  food  and  drink  remain- 
ing unconsumed  should  be  disinfected  and  destroyed.  Food  intended 
for  the  sick-room  should  be  left  outside  the  door,  where  it  may  be  easily 
within  reach  of  the  nurse  or  attendant.  In  some  instances  a  sheet  kept 
moistened  with  a  weak  bichloride  solution  (5  per  cent.)  or  weak  car- 
bolic-acid solution,  may  be  hung  outside  the  door  as  an  added  precau- 
tion. During  the  attack,  and  particularly  throughout  the  stage  of 
desquamation,  especial  attention  should  be  given  to  the  skin  (see  "Gen- 
eral Management")  in  order  to  prevent  any  spread  of  the  contagion 
by  the  desquamating  epidermis. 

After  complete  recovery,  and  at  the  expiration  of  the  period  of 
quarantine,  a  thorough  bath  should  be  given,  clean  clothing  put  on, 
and  the  child  removed  to  an  uninfected  room. 

The  room  recently  occupied  should  be  at  once  thoroughly  disin- 
fected. All  bedding,  linen,  etc.,  should  first  be  soaked  in  one  of  the 
disinfectant  solutions  for  two  hours  or  more,  then  removed  and  boiled. 
The  room  should  then  be  subjected  to  a  thorough  fumigation,  every- 
thing remaining  being  spread  out  so  as  to  allow  free  access  of  the  fumes. 
For  this  purpose  sulphur  may  be  used  (5  pounds  to  a  room),  or,  in 
preference,  formaldehyde-gas.  (See  "Addendum").  After  the  room 
has  remained  closed  for  twenty-four  hours  it  should  be  thrown  open, 
admitting  the  ready  entrance  of  air  and  sunlight  for  twelve  hours. 
The  furniture,  utensils,  bed,  etc.,  may  then  be  thoroughly  washed  with 
carbolic-acid  solution  (1  to  40).  The  mattress  should  be  steamed  and 
the  walls  cleaned  with  bread-crumb  or  one  of  the  compositions  sold  for 
the  purpose.  The  old  pieces  of  carpet  should,  when  possible,  be  de- 
stroyed; if  this  cannot  be  done  they  must  be  steamed.  All  the  books, 
toys,  etc.,  which  have  been  in  the  sick-room  and  constantly  handled 
by  the  patient  during  convalescence  should  be  destroyed.  The  extraor- 


SCARLATINA.  263 

dinary  tenacity  of  the  scarlatinal  virus  makes  this  the  safest  means 
of  absolutely  doing  away  with  all  danger  of  subsequent  contagion  from 
these  sources. 

When  death  occurs,  the  body  should  be  wrapped  in  a  cloth  wrung 
out  of  a  solution  of  sulphate  of  zinc,  8  ounces;  common  salt,  -I  ounces; 
and  water,  1  gallon.  Burial  should  take  place  as  soon  after  death  as 
is  possible,  and  should  be  private. 

MANAGEMENT  OF  THE  DISEASE. 

General  Hygiene. — The  hygiene  of  the  sick-room  in  scarlatina  dif- 
fers in  no  important  principles  from  those  involved  in  the  conduct 
of  any  of  the  acute  exanthemata.  Provision  for  an  abundance  of  fresh 
air  and  thorough  ventilation  cannot  be  emphasized  too  strongly.  Dur- 
ing the  milder  seasons  of  the  year  the  windows  can  be  kept  sufficiently 
open  to  admit  of  a  constant  stream  of  outside  air,  while  in  winter, 
though  it  may  not  be  possible  to  allow  so  long  or  constant  an  entrance 
of  outside  air,  it  must  be  insisted  upon  that  the  atmosphere  of  the  sick- 
room be  kept  fresh,  pure,  and  cool.  With  an  open  fire-place  this  is 
very  much  more  easily  accomplished.  When  two  rooms  with  a  com- 
municating door  are  available  the  question  of  ventilation  is  much 
simpler,  it  being  possible  under  these  circumstances  to  keep  a  window 
constantly  open  in  the  adjoining  room,  without  regard  to  weather,  all 
draughts  being  controlled  by  the  intermediate  door.  The  temperature 
of  the  room  should  be  kept  between  65°  and  70°  F.  (18°  and  23°  C.), 
and  the  bed  so  situated  as  to  allow  the  freest  admission  of  outside  air, 
at  the  same  time  shielding  the  patient  from  any  exposure  to  drafts, 
either  directly  or  indirectly.  When  the  room  does  not  admit  of  this, 
screens  may  be  used  to  further  protect  the  patient,  though  their  use 
should,  if  possible,  be  avoided.  While  screening  the  eyes  from  direct 
light,  it  is  unnecessary  to  darken  the  room,  as  is  so  often  done,  except 
when  light  is  actually  complained  of,  the  presence  of  a  certain  degree 
of  daylight  being  of  great  hygienic  value.  The  child  should  be  kept 
in  bed  even  in  the  mildest  cases;  the  coverings  should  be  as  light  as 
is  possible,  insuring  protection  against  sudden  changes  in  temperature, 
but  not  allowing  too  great  warmth.  How  long  the  patient  shall  re- 
main in  bed  must,  in  many  instances,  be  decided  by  the  individual  case. 
As  a  general  rule,  it  may  be  said  that  a  child  should  be  kept  in  bed  for 
ten  days  after  complete  subsidence  of  the  febrile  stage.  In  this  way 
only  can  the  danger  of  late  renal  complication  be  avoided,  while  daily 


264  THE    ACUTE    EXANTHEMATA. 

examinations  of  the  urine  are  our  only  guide  as  to  just  what  changes 
may  be  taking  place. 

Throughout  the  course  of  the  disease  a  tepid  sponge-bath  should 
be  given  twice  a  day.  As  a  therapeutic  agent  in  diminishing  the  ten- 
sion of  the  skin  and  aiding  in  its  eliminative  functions  such  baths  are 
of  great  service  and,  as  a  rule,  extremely  grateful  to  the  patient.  With 
the  commencement  of  desquamation,  and  earlier,  in  those  cases  in 
which  the  eruption  is  associated  with  itching,  the  body  should  be  care- 
fully anointed  from  head  to  foot  with  cold  cream,  carbolized  vaselin 
(2  per  cent.),  eucalyptus-oil,  lanolin,  or  cacao-butter. 

When  vaselin  alone  proves  too  irritating,  as  it  sometimes  does  in 
young  children,  it  may  be  used  with  lanolin  and  olive-oil,  as  follows: — 

B  Olei   oliva?    3j     (  4.0) . 

Vaselini, 

Lanolini aa  q.  s.  ad  3ij    (60.0). 

M.     Signa:    Apply  locally. 

The  addition  of  menthol,  as  advised  by  Forchheimer,  in  from  1- 
to  2-per-cent.  strength,  will  commonly  give  immediate  relief  in  chil- 
dren when  the  itching  is  extreme.  Carbolic  acid  may  be  added  to  the 
ointment  in  2-per-cent.  strength  in  place  of  menthol,  as  a  mild  anti- 
septic, though  it  must  be  admitted  that  it  cannot  have  any  marked  anti- 
septic properties  unless  used  in  such  strength  as  to  endanger  life. 

Diet. — Throughout  the  first  two  weeks  the  diet  in  scarlatina 
should  consist  chiefly  of  liquids,  while  during  convalescence  it  must  be 
controlled  largely  by  the  age  and  general  condition  of  the  patient.  In 
the  febrile  stage  and  well  on  into  the  second  week  milk,  either  alone 
or  diluted  with  barley-water,  should  be  given  exclusively,  and  water 
should  be  allowed  in  abundance,  either  distilled  or  as  soda-water  or  one 
of  the  aerated  waters.  By  the  end  of  the  second  week  strained  soup, 
beef-tea,  mutton  or  chicken  broth  and  junket  may  be  added,  and,  as 
the  general  condition  improves,  the  temperature  remaining  down  and 
the  urine  normal,  the  diet  may  be  gradually  increased  by  the  addition 
of  oatmeal  gruel,  custard,  lightly  boiled  eggs,  and  soft  toast.  Later, 
fish,  baked  potatoes,  fowl,  and  finally  meat  may  be  allowed.  In  mild 
and  uncomplicated  cases  ripe,  fresh  fruit  may  be  given  after  the  first 
week.  As  the  essential  objects  in  the  diet  of  scarlatina  are  to  supply 
sufficient  nourishment  for  the  maintenance  of  the  patient,  at  the  same 
time  admitting  of  no  unnecessary  work  on  the  part  of  the  already  over- 
taxed organism;  and  to  aid,  so  far  as  possible,  in  the  elimination  of  the 


SCARLATINA.  265 

poison  through  the  kidneys,  so  peculiarly  susceptible  to  the  scarlatinal 
virus,  the  absolute  restriction  during  the  early  weeks  to  a  milk  diet, 
together  with  an  abundance  of  water,  is  the  safest  and  most  rational 
plan.  While  perhaps,  in  a  large  series  of  cases,  an  absolute  milk  diet 
may  not  show  any  marked  lessening  in  the  frequency  of  nephritis,  such 
limitation  is  certainly  on  the  safe  side.  It  is  interesting  to  note,  in  this 
connection,  the  great  diversity  of  opinion  in  reference  to  the  all-im- 
portant question  of  diet,  many  writers  allowing,  during  the  febrile 
course,  soups,  broths,  and  even  eggs,  in  addition  to  milk;  while  other 
authorities  insist  upon  an  absolute  milk  diet.  Moizard  (loc.  cit.,  p.  158), 
following  Jaccoud,  attaches  great  importance  to  an  absolute  milk  diet 
as  producing  the  fewest  intestinal  toxins,  at  the  same  time  being  easy  of 
digestion,  and,  above  all,  as  aiding  in  diuresis. 

In  many  cases  of  scarlatina  the  problem  of  feeding  is  most  diffi- 
cult. The  greatly  inflamed  and  often  ulcerated  condition  of  the  throat 
renders  swallowing  extremely  painful,  and  children,  or  even  adults,  will 
resent  any  attempt  to  give  nourishment.  In  these  cases  one  must  give 
small  and  frequently  repeated  amounts  of  liquid  food,  such  as  beef- 
juice  made  from  the  fresh  steak,  egg-albumin,  or  some  one  of  the  meat- 
extracts.  In  rare  instances  it  may  be  necessary  to  pass  a  nasal  tube  or 
to  resort  to  rectal  feeding.  Constipation  may  be  regulated  by  a  mild 
aperient,  as  magnesia  citrate,  or  by  enema. 

Medical  Treatment. — As  there  is  unfortunately  no  specific  treat- 
ment for  scarlatina,  all  endeavors  to  control  the  disease  must  rest,  as 
heretofore,  upon  a  purely  symptomatic  basis.  With  the  discovery,  iso- 
lation, and  cultivation  ol  the  specific  micro-organism,  which  it  is  to  be 
hoped,  in  the  light  of  recent  work  in  this  line,  will  eventually  be  real- 
ized, we  may  hope  for  some  ultimate  solution  of  the  difficulties  involv- 
ing the  treatment,  not  only  of  scarlatina,  but  all  the  acute  exanthemata. 
In  the  experiments  of  Huber  and  Blumenthal409  13  cases  of  scarlet 
fever  were  treated  by  the  injection  of  serum  obtained  from  the  blood 
of  patients  convalescent  from  the  disease.  Of  these,  8  showed  no 
marked  results,  in  3  an  apparently  pronounced  and  beneficial  reaction 
was  seen,  while,  of  the  remaining  2,  1  showed  no  reaction  and  1  was 
thrown  out  because  of  other  complications.  In  certain  instances  the 
use  of  antistreptococcic  serum  has  given  positive  results,410  while,  again, 
in  many  cases  no  such  results  have  followed  its  administration.  Bagin- 


409  Huber  and  Blumenthal:  Berliner  klin.  Woch.,  No.  31,  1897,  pp.  671  et  seq. 

410  See  Jour,  of  the  Amer.  Med.  Assoc.,  April  8,  1899.    E.  M.  Landis  reports  a  strik- 
ing case  of  recovery  following  its  use. 


THE    ACUTE    EXANTHEMATA. 

sky*11  has  reported  a  series  of  48  cases  of  scarlet  fever,  treated  with 
Marmorek's  antistreptococcic  serum,  of  which  7  were  fatal,  or  a  mor- 
tality of  14.6  per  cent.  Theoretically,  it  should  be  of  real  value  in  all 
cases  complicated  by  a  streptococcic  angina. 

In  all  cases  of  scarlatina  characterized  by  grave  septic  infection, 
and  particularly  in  threatened  uraemia,  the  subcutaneous  injections  of 
large  amounts  of  sterile  salt  solution  should,  upon  theoretical  grounds 
at  least,  be  of  some  value.  In  a  few  instances  when  thus  used  the 
writer  has  seen  temporary  relief  in  one  case,  and  has  urgently  advised 
it,  when  not  previously  employed.  Forchheimer  (loc.  cit.,  p.  100)  alone 
makes  a  strong  plea  for  its  more  general  use,  even  suggesting  the  direct 
transfusion  into  a  vein,  or  injection  into  the  serous  cavities  of  sterile 
normal  salt  solution,  with  the  object  of  diluting  the  poison  circulating 
in  the  blood,  and  as  a  mechanical  aid  to  diuresis  and  the  elimination  of 
toxins.  The  positive  and  beneficial  results  of  this  method  in  condi- 
tions closely  analogous  to  those  arising  in  scarlet  fever  justify  us  in 
believing  that  in  certain  cases  of  scarlatina  much  might  be  gained  by 
such  measures  if  adopted  promptly.  In  the  great  majority  of  cases 
with  slight  angina,  but  little  fever,  and  mild  constitutional  symptoms, 
isolation,  rest  in  bed,  diet,  and  nursing,  together  with  the  local  care  of 
the  pharynx,  the  administration  of  a  diuretic  mixture,  the  proper  care 
of  the  skin,  constitute  all  the  treatment  necessary.  It  must  not  be 
forgotten,  however,  that  serious  complications  nlay  arise  at  any  time, 
even  in  the  mildest  case,  and  that  one  should  be  continually  on  guard 
against  any  such  possible  contingency. 

The  Throat. — The  care  of  the  pharynx  in  every  case  of  scarlatina, 
however  mild,  is  of  the  first  importance.  In  adults  and  children  old 
enough  to  gargle  the  use  of  some  mild  antiseptic  solution  every  two 
or  three  hours  during  the  acute  stage  of  the  angina  should  be  insisted 
upon,  while  in  the  very  young  a  spray  must  be  resorted  to.  For  this 
purpose  a  saturated  solution  of  boric  acid;  a  1-per-cent.  solution  of 
carbolic  acid  in  lime-water;  dilute  peroxide  of  hydrogen,  or  the  lo- 
tion given  at  the  end  of  the  volume  may  be  used.  In  addition,  as  a 
means  of  local  relief,  small  pieces  of  cracked  ice  may  be  held  in  the 
mouth,  while  for  the  enlargement  and  tenderness  of  the  lymphatic 
glands  an  ice-bag  or  cold  compresses  must  be  applied.  In  cases  in 
which  the  repeated  use  of  a  spray  is  resented  by  young  children,  a  tea- 
spoonful  of  a  0.5-  to  1.5-per-cent.  solution  of  salicylate  of  soda  may  be 
given  every  hour  or  two,  as  advised  by  Forchheimer  (loc.  cit.,  p.  94). 

411  Baginsky  (A.):  Berliner  klin.  Woch.,  1896,  No.  33,  pp.  340  et  seq. 


SCARLATINA.  267 

In  cases  characterized  by  a  severe  angina,  with  excessive  secretion  and 
accumulation  in  the  throat,  a  spray  should  be  used  regularly  in  addi- 
tion to  the  gargle,  and  often  irrigation  of  the  pharynx  with  hot  water 
to  which  glycerin  has  been  added,  a  drachm  to  the  quart,  affords  great 
relief  to  the  choking  sensation  so  frequently  present  at  this  time. 

Fever. — The  use  of  antipyretic  drugs  for  controlling  the  fever  in 
scarlatina  has  almost  entirely  given  place  to  hydrotherapy,  though  in 
certain  cases  they  may  still  be  found  of  some  value.  Osier  (loc.  cit.,  p. 
80)  says  of  them:  "Medicinal  antipyretics  are  not  of  much  service  in 
comparison  with  cold  water."  If  used,  quinine  and  phenacetin  are  to 
be  preferred.  When  drowsiness,  restlessness,  or  delirium  supervene, 
Henoch  (loc.  cit.,  p.  684)  advises,  in  addition  to  a  tepid  bath,  the  use  of 
a  single  dose  of  either  quinine,  gr.  vii-xv  (0.5  to  1  gramme),  or  phenace- 
tin, gr.  iv-viij  (0.25  to  0.5  gramme),  between  five  and  six  in  the  after- 
noon. Ashby  (loc.  cit.,  p.  271)  recommends  the  use  of  quinine  in  1 
to  3  grain  (0.065  to  0.2  gramme)  doses,  together  with  cold  packs  in 
those  cases  in  which  the  temperature  continues  high.  Phenacetin  may 
be  used  in  the  same  way  in  doses  of  Y4  to  1  grain  (0.016  to  0.065 
gramme),  repeated  as  may  be  necessary.  Antipyrin  and  antifebrin  are, 
as  a  rule,  too  depressing,  and  not  to  be  recommended.  There  exists 
to-day  an  almost  unanimous  opinion  as  to  the  value  of  cold  water,  in 
one  form  or  another,  as  the  safest  and  most  reliable  means  we  have  for 
reducing  the  temperature  in  scarlatina.  Whether  it  be  in  the  form  of 
cold  spongings,  cold  packs,  or  the  cold  bath,  each  of  which  may  be 
applied  to  meet  the  varying  needs  of  the  individual  case,  there  is  no 
better  means  of  controlling,  not  only  the  fever,  but  also  of  influencing 
the  grave  nervous  symptoms  often  accompanying  it.  Moizard  (loc.  cit., 
p.  160)  truly  says:  "Here,  as  in  typhoid  fever,  cold  water  is  of  the 
greatest  service;  not  only  does  it  lower  the  temperature,  but  quiets  the 
nervous  excitement,  inducing  almost  always  a  more  or  less  prolonged 
sleep;  and,  above  all,  it  aids  in  diuresis.  The  action  on  the  pulse  is 
equally  manifest:  in  infants  it  may  fall  from  180  to  150.  The  diar- 
rhoea and  vomiting,  so  frequent  in  the  grave  forms,  is  lessened  or  even 
ceases  under  the  action  of  the  cold  bath.  The  action  of  cold  water  from 
all  these  points  of  view  is  marvelous."  According  to  the  above  author, 
Currie  was  the  first  to  employ  cold  in  scarlet  fever,  so  long  ago  as  1798, 
in  the  form  of  cold  affusions.  Von  Jiirgensen  (loc.  cit.,  p.  238)  con- 
siders the  use  of  cool  baths  the  best  means  of  controlling  scarlatina 
from  its  invasion  until  the  disappearance  of  all  severe  symptoms;  bath- 
ing whenever  the  rectal  temperature  reaches  104°  F.  (40°  C.),  the 


268  THE   ACUTE    EXANTHEMATA. 

temperature  of  the  bath  for  young  children  being  68°  F.  (20°  C.)  and 
its  duration  but  five  minutes.  With  older  children  and  adults  the  tem- 
perature of  the  water  is  59°  F.  (15°  C.),  and  the  bath  is  prolonged 
from  five  to  fifteen  minutes.  Henoch  (loc.  cit.,  p.  684),  on  the  other 
hand,  while  advising  against  the  cold  bath  as  tending  to  produce  col- 
lapse, which  opinion  is  shared  by  Jacobi412  in  this  country,  heartily  in- 
dorses the  use  of  cold  sponges  and  cold  packs.  The  application  of  the 
cold  bath  at  the  temperature  advised  by  von  Jiirgensen  might  readily, 
for  many  reasons,  prove  impracticable,  and  the  writer  has  seen  quite  as 
satisfactory  results  follow  a  bath  given  at  a  temperature  of  10°  or  even 
15°  higher. 

In  severe  cases  with  marked  cerebral  symptoms  and  a  rapidly 
rising  and  persistent  temperature  of  103°  to  105°  F.  (39.5°  to  40.5° 
C.),  in  addition  to  the  cold  pack,  which  frequently  serves  every  pur- 
pose, a  cold  bath  may  be  given,  the  temperature  at  the  outset  being 
80°  F.  (26.6°  C.)  or  even  higher.  It  is  then  gradually  reduced  to  the 
desired  point.  Given  in  this  way,  there  is  generally  less  opposition  on 
the  part  of  the  family,  while  the  results  are  almost,  if  not  equally,  satis- 
factory. Cases  characterized  by  extreme  restlessness,  marked  delirium, 
and  convulsions  yield,  as  a  rule,  more  readily  to  an  extremely  hot  bath, 
at  a  temperature  ranging  from  105°  to  110°  F.  (40.5°  to  43.3°  C.), 
while  with  grave  cerebral  disturbance,  as  shown  by  drowsiness,  stupor, 
and  even  coma,  the  patient  may  be  placed  in  a  tepid  bath  and  cold  water 
poured  directly  upon  the  head  for  from  five  to  ten  minutes,  as  advised 
by  Steff  en.413  An  ice-cap  or  cloths  wrung  out  of  iced  water  may  be  used 
throughout  the  course  of  the  disease  when  the  temperature  is  high. 

As  contra-indications  to  the  use  of  the  cold  bath  in  scarlatina,  von 
Jiirgensen414  gives  the  following: — 

"All  demonstrable  anatomical,  and  especially  inflammatory, 
changes  in  the  heart;  all  evidences  of  dyspnoea  associated  with  nar- 
rowing of  the  upper  respiratory  tract;  haemorrhages  from  the  nose, 
throat,  eroded  blood-vessels,  or  in  the  haemorrhagic  diathesis;  and  all 
inflammations  involving  the  joints." 

GENERAL  INDICATIONS. 

In  mild  cases  of  scarlet  fever  the  treatment  above  outlined  will 
generally  suffice.  With  moderate  fever,  good  pulse,  and  without  gas- 

418  Jacobi  (A.):  "Therapeutics  of  Infancy  and  Childhood"  (Philadelphia,  1898),  p. 
237. 

«»  Steffen  (loc.  cit.,  p.  231). 

"4  Von  Jurgensen  (loc.  cit.,  pp.  243  et  set].). 


SCARLATINA.  269 

trie  irritability  after  an  initial  dose  of  calomel,  the  tincture  of  the  chlo- 
ride of  iron  may  be  given,  either  alone  or  with  dilute  hydrochloric 
acid  as  follows: — 

ft  Tinct.   ferri   chloridi f3ij  (   7.0) . 

Acidi  hydrochloric!  diluti f3j  (  3.5). 

•  Syr.  limonis  fgj  (30.0). 

Aquae  q.  s.  ad  fgiij  (90.0) . 

M.  Signa:  Teaspoonful  every  two  or  three  hours. 

Or,  as  recommended  by  Yeo415: — 

1$  Liq.  ammonias  aeetatis f^iss  (  37.5). 

Potass,  chlorati    f3j  (     3.5) . 

Syr.  limonis   f^ss  (   15.0). 

Aquae   q.  s.  ad  f^vj  (170.0). 

Misce  et  fiat  mistura. 

Signa:  One  to  three  teaspoonfuls  every  four  or  five  hours,  according  to 
age. 

Tincture  of  aconite  may  be  added  in  1/2  minim  doses  to  the  above, 
in  cases  characterized  by  a  rapid,  hard  pulse,  but  should  be  omitted 
after  forty-eight  hours.  Moizard  (loc.  cit.,  p.  156)  gives  a  solution  of 
ammonium  acetate,  as  a  rule,  during  the  first  days,  omitting  it  when  the 
rash  is  fully  developed. 

Although  in  many  instances  simple  uncomplicated  scarlatina  may 
be  carried  to  a  successful  termination  without  the  need  of  stimulation, 
indications  may  demand  it  at  any  time  during  the  course  of  the  dis- 
ease, and  are  to  be  found,  as  in  all  acute  infections,  in  the  character  of 
the  heart's  action  and  the  pulse.  The  moment  the  first  sound  of  the 
heart  becomes  weak,  or  the  two  sounds  lose  their  normal  tone,  and  any 
threatening  change  is  noted  in  the  pulse,  stimulation  must  be  insisted 
upon.  For  this  purpose  brandy  or  whisky  in  suitable  doses  may  be 
given  and  repeated  when  necessary.  If  objectionable,  champagne, 
with  an  abundance  of  finely  cracked  ice,  is  often  grateful,  and  answers 
the  purpose,  at  least  temporarily,  equally  well.  Strychnine  may  be 
given  every  three  or  four  hours:  1/100  grain  (0.00065  gramme)  to  a 
child  of  three  three  times  a  day.  When  the  pulse  is  weak,  soft,  and 
of  low  tension  Holt  (loc.  cit.)  advises  the  use  of  digitalis. 

With  the  appearance  of  grave  symptoms  of  a  septic  or  toxic  char- 
acter, high  fever;  a  small,  weak,  rapid,  or  even  irregular  pulse;  cyano-% 
sis;  cold  extremities,  and  threatened  collapse,  the  question  of  stimu- 


415  Yeo  (I.  B.):  "Manual  of  Treatment"  (Philadelphia,  1893),  vol.  ii,  p.  605. 


270  THE    ACUTE    EXANTHEMATA. 

lation  becomes  at  once  of  the  first  importance.  Brandy  or  whisky  may 
be  given  in  teaspoonful  doses  as  often  as  necessary,  and  in  addition  5 
to  15  minims  of  aromatic  spirit  of  ammonia,  alone  or  with  equal  parts 
of  ether  in  strong  camphor-water,  may  be  given  hourly.  Henoch  (loc. 
cit.,  p.  685)  considers  camphor  of  the  greatest  value  in  this  condition, 
giving  Y2  to  3  grains  (0.032  to  0.2  gramme)  every  two  or  three  hours 
hypodermically,  or  in  solution  with  ether  (camphor,  1;  in  ether,  10). 
Musk,  in  doses  of  */,  to  3  grains  (0.032  to  0.2  gramme),  may  be  given 
every  two  hours.  When  collapse  is  imminent,  Moizard  (loc.  cit.,  p.  161) 
advises  caffeine  in  doses  of  3/4  to  1  1/2  grains  (0.05  to  0.1  gramme),  or 
the  sulphate  of  sparteine  in  distilled  water  in  doses  of  1/3  grain  (0.02 
gramme)  or  more,  hypodermically;  while  with  grave  toxic  symptoms 
and  a  low  temperature,  Jacobi  (loc.  cit.,  p.  237)  recommends  morphine 
in  doses  of  1/50  to  1/20  grain  (0.0013  to  0.0032  gramme),  to  be  repeated 
as  necessary.  For  cardiac  dilatation  digitalis  or  strophanthus  may  be 
used,  as  seems  best. 

When  restlessness  and  active  delirium  cannot  be  controlled  by 
means  of  hydrotherapy,  bromide  of  potassium  or  chloral-hydrate,  in 
addition  .to  the  hot  bath,  may  be  given.  When  it  is  impossible  to  give 
the  hot  bath,  a  hot  pack  may  be  substituted.  In  rare  cases  local  de- 
pletion by  leeches  may  be  of  the  greatest  value,  and  in  one  case  at  least 
the  writer  is  confident  that  a  fatal  issue  was  thus  prevented. 

TREATMENT  OF  THE  COMPLICATIONS. 

Angina. — In  septic  cases  with  excessive  involvement  of  the  phar- 
ynx, associated  with  active  inflammation,  ulceration,  or  the  develop- 
ment of  a  false  membrane,  active  measures  must  be  employed  to  pre- 
vent the  extension  of  the  local  process.  An  ice-bag  or  iced  cloths 
should  be  kept  constantly  applied  over  the  throat  and  neck,  while  the 
pharynx  and  mouth  should  be  carefully  sprayed,  and  thoroughly 
washed  out  every  two  or  three  hours  with  a  strong  antiseptic  solution. 
For  this  purpose  hydrogen  peroxide  (2  to  3  per  cent.);  potassium  per- 
manganate, 15  grains  to  1  ounce  of  water  (1  gramme  to  30  cubic  centi- 
metres); or  a  solution  of  chlorate  of  potassium  of  the  same  strength 
may  be  used. 

A  strong  acid  solution  of  chlorine- water  is  heartily  indorsed  by 
many  English  writers.416  This  is  prepared  by  adding  strong  hydro- 
chloric acid  to  powdered  potassium  chlorate  in  a  large  bottle  filled  with 

"•  See  Ashby,  Caiger,  Moore,  and  Yeo  (loc.  cit.). 


SCAKLATINA.  271 

water,  carefully  stoppered,  and  then  thoroughly  shaken;  the  propor- 
tions being:  strong  hydrochloric  acid,  5  minims;  powdered  potassium 
chlorate,  9  grains;  and  water,  1  ounce  (HC1,  0.30  cubic  centimetre; 
potass,  chlor.,  0.6  gramme;  water,  30  cubic  centimetres).  In  all  cases 
of  membranous  pharyngitis  Jacobi  (loc.  cit.,  p.  260)  recommends  the 
internal  administration  of  potassium  chlorate,  adding,  at  the  same  time, 
a  warning  against  too  large  doses.  ISTot  more  than  15  grains  (1  gramme) 
should  be  given  in  twenty-four  hours  in  divided  doses,  every  hour  or 
two,  to  a  child  of  one  year. 

When  the  membrane  shows  the  slightest  tendency  to  spread  be- 
yond /the  tonsils,  a  bacteriological  examination  should,  if  possible,  be 
made,  and,  if  Klebs-Loeffler  bacilli  are  found,  diphtheria  antitoxin 
should  be  given  at  once,  as  in  a  true  diphtheria.  When  not  found,  and 
the  membranous  inflammation  is  of  pure  streptococcic  origin,  antistrep- 
tococcic  serum  may  be  used  with  the  hope  of  limiting  the  process.  If 
uncertainty  exist  and  a  bacteriological  examination  be  not  available,  the 
administration  of  the  antistreptococcic  serum  in  the  early  membranous 
angina  of  scarlatina  is  at  least  a  rational  plan  and  can  do  no  harm. 
When  the  local  process  extends  to  the  posterior  nares  and  is  accom- 
panied by  a  profuse  coryza,  with"  acrid,  irritating  discharges,  the  nos- 
trils must  be  thoroughly  irrigated  with  a  mild  antiseptic  solution,  as 
dilute  peroxide  of  hydrogen  or  dilute  chlorine-water,  care  being  taken 
that  the  solution  be  not  too  strong  and  irritating.  Henoch417  advises 
the  use  of  a  1-per-cent.  carbolic-acid  solution  in  these  cases. 

In  the  event  of  grave  ulcerative  or  gangrenous  inflammation  of  the 
tonsils  Heubner418  advises  direct  injection-of  a  3-  to  5-per-cent.  carbolic- 
acid  solution  into  the  tonsillar  substance.  At  the  Children's  Hospital  in 
Vienna  this  has  been  followed,  in  some  instances,  by  necrosis,  and  is 
regarded  as  of  doubtful  value.419  In  these  cases  a  5-per-cent.  solution 
of  carbolic  acid  in  glycerin  or  a  saturated  solution  of  salicylic  acid  in 
alcohol  may  be  applied  locally.  The  use  of  the  actual  cautery,  though 
advised  as  a  last  resort,  may  be  difficult  and  even  impossible.  The 
occurrence  of  suppuration,  and,  rarely,  of  a  retropharyngeal  abscess, 
demands  free  incision. 

Diphtheria. — Diphtheria  complicating  the  late  stage  of  scarlatina 
should  be  treated  as  such  by  the  administration  of  antitoxin  in  large 
amount,  and  the  local  application,  every  four  hours,  of  Loeffler's  solu- 


«7  Henoch  (E.):  "Charite  Annalen"  (loc.  cit.,  p.  562). 

418  Heubner:  See  Henoch  (Vor.,  loc.  cit.,  p.  686). 

419  Writer's  personal  notes. 


272  THE    ACUTE    EXANTHEMATA. 

tion,420  by  the  application  of  ice-bags,  and  by  stimulation  as  may  be 
indicated. 

Involvement  of  the  Lymphatics. — The  enlargement  and  tenderness 
of  the  lymphatic  glands  in  the  neck  should  be  treated  by  the  applica- 
tion of  cold,  in  the  form  of  ice-bags  or  iced  cloths,  and  when  glandular 
inflammation  persists  cold  applications  should  be  continued  for 
twenty-four  to  forty-eight  hours.  If  the  enlargement  increases,  poul- 
tices may  be  resorted  to,  and  the  moment  fluctuation  is  made  out  the 
gland  should  be  freely  incised  and  the  pus  evacuated;  then  thoroughly 
irrigated  and  dressed  antiseptically.  With  the  rare .  occurrence  of  a 
general  cellular  infiltration  and  cellulitis,  characterized  by  tense  in- 
duration of  the  deeper  tissues  of  the  neck, — the  so-called  "angina 
Ludovici/' — it  is  frequently  wiser  not  to  delay  until  suppuration  occurs, 
but  to  relieve  the  condition  at  once  by  free  incision.  Forchheimer  (loc. 
cit.,  p.  195)  indorses  painting  over  the  inflamed  gland  with  flexible  col- 
lodion as  a  means  of  preventing  absorption  from  the  superficial  lym- 
phatics; and  has  never  seen  a  case  of  angina  Ludovici  when  this 
method  had  been  employed. 

Otiiis.  —  The  occurrence  of  otitis  media  in  scarlet  fever  often 
first  becomes  evident  by  the  escape  of  pus  from  the  external  auditory 
canal,  that  early  interference  on  the  part  of  the  physician  is  frustrated, 
and  the  treatment  resolves  itself  into  the  subsequent  care  of  the  ear. 
Too  great  emphasis  cannot  be  placed  upon  the  value  of  thorough  irri- 
gations of  the  fauces,  in  every  case  of  scarlatina,  as  a  means  of  pre- 
venting the  extension  of  the  inflammatory  process  to  the  middle  ear. 
This  is  naturally  not  always  easy,  and  repeated  spraying,  if  bitterly 
resented,  may,  when  forced,  result  in  more  harm  than  good. 

The  occurrence  of  earache,  however  slight,  or  of  pain  referred  to 
either  ear,  should  be  closely  watched  for.  For  the  early  earache  the 
instillation  of  simple  salt  solution  or  water,  as  hot  as  can  be  borne, 
may  give  great  relief.  A  small  thin  bag,  which  is  easily  and  quickly 
made,  may  be  filled  with  common  salt,  and  applied  as  hot  as  can  be 
tolerated.  If  no  relief  follow,  a  few  drops  of  a  warm  solution  of  cocaine 
(3  to  5  per  cent.)  may  be  dropped  into  the  canal.  This  serves  a  double 
purpose:  relieving  the  pain  and  at  the  same  time  allowing  a  freer 
examination  of  the  ear  with  a  speculum.  As  soon  as  any  evidence  of 
the  presence  of  pus  appears,  as  shown  by  the  opacity  and  bulging  of 


*20  Menthol,  gr.  cl  (10  grammes);  dissolved  in  toluol  to  fJifSimxl  (36  cubic  centi- 
metres); liquor  ferri  sesquichlor.,  f3i»iviij  (4  cubic  centimetres);  and  absolute  alcohol, 
fjij  (60  cubic  centimetres). 


SCARLATINA.  273 

the  membrane,  it  should  be  incised,  and  the  ear  irrigated  two  or  three 
times  daily  with  a  warm  solution  of  equal  parts  of  hydrogen  peroxide 
and  boiled  water,  being  protected  externally  by  large  compresses  of 
sterile  gauze.  If  the  membrane  close  prematurely,  the  incision  should 
be  repeated.  No  danger  can  result  from  repeated  incisions,  and  the 
ready  escape  of  all  pus  as  it  accumulates  is  of  vital  importance.  When 
the  discharge  persists  throughout  convalescence,  and  tends  to  become 
chronic,  the  irrigations  must  be  continued  at  least  twice  daily.  The 
hydrogen  peroxide  may  be  replaced  by  carbolic  acid  (2  to  3  per  cent.), 
by  lysol  (1  to  2  per  cent.),  or  resorcin  (2  to  3  per  cent.).  Later  insuffla- 
tions of  finely  powdered  boric  acid  once  or  twice  a  day  may  be  used, 
always  irrigating  the  ear  thoroughly  before  each  insufflation.421 

Nephritis. — Although,  in  rare  instances,  renal  complications  may 
arise,  of  which  the  urinary  examination  gives  no  warning,  our  knowl- 
edge of  such  changes  depends  absolutely  upon  daily  examinations, 
both  chemical  and  microscopical,  together  with  an  accurate  record  of 
the  amount  passed  during  each  twenty-four  hours.  With  the  first  evi- 
dence of  renal  inflammation,  every  endeavor  should  be  made  to  aid  in 
the  eliminative  functions  of  the  skin  and  bowels,  to  relieve  the  kid- 
neys of  all  unnecessary  work,  and  to  lower  the  blood-pressure. 

The  child  must  be  kept  in  bed,  and  the  diet  should  be  exclusively 
of  milk.  Water  may  be  given  freely  and  lemonade  is  allowable. 

The  action  of  the  skin  is  aided  by  hot  baths  or  packs.  In  the 
former  the  child  is  usually  placed  in  a  bath  at  a  temperature  ranging 
from  100°  F.  (37.8°  C.)  to  110°  F.  (43.3°  C.)  and  allowed  to  remain 
for  ten  to  fifteen  minutes,  during  which  the  surface  of  the  body  is 
gently  rubbed.  He  is  then  taken  out  and  placed  between  blankets 
without  being  dried,  in  which  he  is  left  for  an  hour.  After  this  the 
body  is  thoroughly  dried,  and  the  child  placed  in  a  warm  bed.  In 
giving  the  hot  pack  the  child  is  wrapped  in  a  blanket  wrung  out  of 
hot  water  at  100°  F.  (37.8°  C.)  and  then  covered  by  a  dry  blanket,  over 
which  is  placed  a  rubber  cloth.  This  may  be  repeated  as  often  as 
necessary. 

Under  some  circumstances  the  hot-atr  bath  proves  more  efficient, 
and  may  be  given  as  follows:  The  patient  is  covered  with  a  blanket, 
.while  on  either  side  hot  flat  irons  or  hot  bricks  are  placed  so  protected 
as  to  prevent  any  possible  danger  of  a  burn.  A  mackintosh  is  then 
placed  over  these,  and  over  all  a  second  blanket.  Sweating  can  usually 


421  Politzer  (A.):  "Lehrbuch  der  Ohrenheilkunde"  (Stuttgart,  1893),  pp.  351-353. 

is 


274  THE    ACUTE    EXANTHEMATA. 

be  quickly  induced  by  this  method,  and  is  often  profuse.  The  use  of 
the  ordinary  flat  iron  may  appear  crude,  but  they  are  commonly  avail- 
able in  every  household,  and  the  writer  has  seen  them  used  in  this  way 
with  great  success  in  threatened  uraemia. 

Pilocarpine  may  be  given  hypodermically  in  doses  of  1/30  to  yi6 
grain  (0.0022  to  0.004  gramme)  to  children  from  two  to  ten  years 
of  age,  but  great  caution  should  be  used  in  its  administration,  and, 
when  marked  bronchial  secretion  exists,  it  is  safer  to  omit  it. 

After  a  dose  of  calomel  the  bowels  may  be  kept  open  by  a  mild 
saline  purge,  such  as  citrate  of  magnesia. 

When  uraemia  threatens,  free  catharsis  should  be  induced  at  once, 
followed  by  the  hot  bath,  pack,  or  the  hot-air  bath.  In  addition,  pilo- 
carpine  may  be  given,  while  nitroglycerin,  if  indicated,  may  be  used 
to  lower  the  blood-pressure,  and,  if  nervous  symptoms — such  as  slight 
or  marked  twitchings  or  actual  convulsions — develop,  chloroform  may 
be  administered  or  chloral  and  opium  given  internally.  Local  bleed- 
ing by  leeches  or  venesection  may  often  be  successfully  resorted  to. 
With  the  existence  of  marked  dropsy  and  general  anasarca,  the  danger 
of  possible  effusion  into  the  serous  cavities  of  the  body  must  be  borne 
in  mind,  and  should,  when  possible,  be  relieved  by  aspiration.  Digitalis 
or  strophanthus  may  be  given  as  a  diuretic.  For  the  subsequent 
anasmia  common  in  nephritis  iron  in  some  form  should  be  given.  In 
all  cases  complicated  by  nephritis  the  return  to  the  normal  diet  should 
be  slow  and  guarded. 

Arthritis. — If  the  acute  synovitis  or  arthritis  of  scarlatina  is  the 
result  of  a  streptococcic  infection,  as  is  commonly  held  to-day,  it  should 
obviously  be  treated  as  such,  and  not  as  rheumatism.  In  mild  cases 
belladonna  and  chloroform  liniment  may  be  used.  In  more  severe 
forms  the  joints  involved  should  be  protected  with  cotton-wool  and 
bandaged.  If  the  symptoms  are  intense  and  persistent,  antistrepto- 
coccic  serum  may  be  tried.  Though  not  yielding  as  readily  as  true 
rheumatism  to  the  salicylates,  they  may  be  given  in  the  form  of  sali- 
cylic acid  or  the  salicylate  of  soda.  With  the  occurrence  of  suppura- 
tion the  joint  must  be  opened.  Tenosynovitis  may  be  treated  locally 
by  cold  applications,  and  true  articular  rheumatism  should,  of  course, 
be  treated  as  such. 

Endocarditis  or  Pericarditis. — Throughout  the  course  of  the  dis- 
ease the  heart  demands  most  careful  watching,  and  particularly  is  this 
true  when,  even  in  the  absence  of  other  grave  symptoms,  any  synovia! 
or  articular  inflammation  is  present.  The  danger  of  endocarditis  or 


SCARLATINA.  275 

pericarditis  in  these  cases  must  not  be  forgotten.  They  must  be  treated 
by  the  application  of  ice-bags  over  the  heart,  by  the  use  of  digitalis, 
and  such  other  stimulation  as  may  be  necessary.  With  pericarditis  the 
danger  of  possible  effusion  into  the  pericardial  sac,  sometimes  demand- 
ing paracentesis,  is  to  be  remembered. 

Bronchitis,  Pneumonia,  and  Pleurisy. — Complications  on  the  part 
of  the  respiratory  system — as  severe  bronchitis,  pneumonia,  or  pleu- 
risy— are  to  be  treated  as  when  occurring  under  other  circumstances. 
The  frequency  with  which  the  inflammatory  pleural  exudate  in 
scarlatina  becomes  purulent  has  been  noted.  This  danger  must  be 
carefully  looked  for,  and,  if  present,  immediate  resection  of  a  rib 
and  evacuation  must  be  insisted  upon. 

Stomatitis. — As  a  rule,  nothing  more  is  required  in  the  way  of 
local  treatment  of  the  mouth  than  has  been  already  outlined.  Thor- 
ough asepsis  is  the  best  prophylactic  against  stomatitis.  In  severe  cases 
characterized  by  rapidly  ulcerating  and  sloughing  surfaces  local  appli- 
cations may  be  made  with  a  10-per-cent.  solution  of  silver  nitrate  or 
a  l-to-500  solution  of  the  bichloride  of  mercury,  though  the  latter 
cannot  be  used  without  danger  in  children.  If  necessary,  the  part  may 
be  curetted,  or  the  actual  cautery  applied  tinder  an  anaesthetic. 

G astro-enteritis. — The  presence  of  marked  gastric  irritability,  with 
excessive  vomiting,  may  seriously  complicate  the  treatment  of  scar- 
latina. Although  frequently  obstinate,  it  may  be  relieved  by  small 
doses  of  calomel,  1/12  grain  (0.0054  gramme);  bismuth  subnitrate,  5 
to  10  grains  (0.32  to  0.65  gramme);  or  bicarbonate  of  soda  in  the  same 
doses,  repeated  every  hour  or  two.  When  persistent,  opium  may  be 
tried  in  doses  of  1/60  to  1/150  grain  (0.001  to  0.00043  gramme)  given 
every  two  hours  or  oftener;  or  the  muriate  of  cocaine  in  doses  of  1/20 
to  Vso  grain  (0.0032  to  0.0013  gramme)  may  be  used.  All  nourish- 
ment must  be  withheld  for  a  number  of  hours,  albumin-water  being 
given  when  necessary.  Normal  feeding  must  be  very  slowly  resumed, 
small  amounts  at  frequent  intervals  being  allowed  until  that  time. 

Diarrliosa  occurring  early  in  the  disease  frequently  subsides  dur- 
ing the  first  few  days,  and  should  be  let  alone.    If  persistent  or  occur- 
ring later  in  the  course  of  the  attack,  it  should  be  controlled  by  bis- 
muth subnitrate  given  with  salol,  the  deodorized  tincture  of  opium, 
•  or  starch-water  and  laudanum  enemata. 

EDWARD  PERKINS  CARTER. 


CHAPTEE  VI. 

KUBEOLA. 

(Measles,422  Morbilli42* ;    French,  rougeole;    German,  masern, 
flecken;    Italian.  morMlll,  rosolia;    Spanish,  scrampidn.) 

DEFINITION. 

MEASLES  is  an  acute,  eruptive,  febrile  disorder,  usually  occurring 
in  childhood  or  early  adolescence,  and  is  caused  by  a  specific  contagium. 
It  is  characterized  by  coryza  or  a  congestive  disturbance  of  the  upper 
air-passages,  conjunctiva?,  etc.,  together  with  a  distinctive  macular  or 
phlyctenular  eruption,  which  is  accompanied  by  a  considerable  ele- 
vation of  temperature.  It  is  both  infectious  and  contagious,  and  im- 
munity is  usually  conferred  by  one  attack. 

Measles  presents  less  variability  than  both  variola  and  scarlatina, 
although  its  conspicuous  features  are  by  no  means  uniform.  Syden- 
ham,  in  conformity  with  the  teaching  of  the  seventeenth  century,  re- 
garded the  fever  as  the  cardinal  symptom,  while  Hebra  places  this  dis- 
ease among  the  acute,  exudative,  contagious  dermatoses.  We  of  the 
present  look  upon  measles  as  the  result  of  a  specific  living  contagium, 
which,  gaining  access  to  a  susceptible  organism,  gives  rise  to  a  regular 
sequence  of  symptoms,  liable  to  some  variation  according  to  individual 
peculiarities  and  conditions  of  environment  or  general  sanitation. 
Hence,  such  terms  as  "black  measles,"  "camp  measles,"  "false  measles," 
etc.,  commonly  employed  by  the  laity  and  sometimes  by  medical  men  to 
designate  haemorrhagic  or  other  unusual  clinical  forms,  while  they  may 
have  no  definite,  scientific  meaning,  usually  indicate  some  aberration  or 
departure  from  the  normal,  and  as  such  will  receive  further  considera- 
tion in  the  text.  The  normal,  or  ordinary,  form,  of  moderate  severity, 
constitutes  the  type,  and  will  first  receive  attention,  after  which  the  less 
frequent  and  anomalous  forms  will  conclude  the  description. 


422  Derived  from  an  old  English  word  meaning  a  spot,  probably  derived  from  the 
German  masern,  spots,  which,  in  turn,  may  be  derived  from  the  Sanskrit  masura,  spots. 

423  For  derivation  see  page  17. 

(276) 


RUBEOLA.  277 

RUBEOLA  VULGABIS  (Morbilli  Regulares). 
SYMPTOMATOLOGY. 

REGULAR,  OR  XORMAL,  COURSE. 

For  clearness  of  description  the  symptoms  of  measles  may  best  be 
studied  under  groups,  denominated  periods,  or  stages,  of  which  there 
are  four.  The  line  of  demarkation  between  them  is  not  clearly  drawn, 
and  in  the  first,  or  prodromal,  stage  no  special  symptoms  are  usually 
present,  yet  the  ensemble  is  sufficiently  distinctive  in  each  stage  to 
warrant  a  separate  description. 

PERIOD  OF  INCUBATION.  —  After  exposure  to  measles  a  certain 
time  elapses  before  any  evidence  of  the  disease  appears.  This  is  called 
the  period  of  incubation,  or  latent  stage,  and  ranges  from  9  to  14  days, 
most  frequently  11  days.  In  144  cases  Holt424  found  the  period  of 
incubation  in  66  per  cent,  to  be  from  11  to  14  days.  That  this  is 
subject  to  great  variability  may  be  seen  from  the  following  table  taken 
from  his  work: — 

Incubation  less  than     9  days,     3  cases. 
"  from     9  to  10      "       22 

"      11    "    14      "       95       "   • 
"      15    "    17      "        19       " 
"      18    "    22      "         5       " 

In  60  cases  observed  by  Haig  Brown,425  at  the  Charter-House 
School  the  period  was  14  days.  On  the  other  hand,  cases  have  been 
recorded  in  which  only  5  days  have  elapsed  between  exposure  and  the 
first  appearance  of  the  disease.  When  measles  occurs  a  second  time, 
the  stage  of  incubation  is  said  by  Graham426  to  be  from  18  to  21  days, 
and,  when  inoculated,  to  be  much  shorter,  ranging  from  8  to  10  days. 
We  have  reason  to  believe,  however,  that  the  poison  is  not  wholly 
inactive,  even  from  the  moment  of  reception,  and  not  infrequently 
some  slight  constitutional  disturbances  are  complained  of  a  day  or 
two  before  the  advent  of  the  more  distinctive  evidences  of  infection. 
In  determining  quarantine  regulations  these  extremes  must  be  taken 
into  account. 

ACTUAL   ATTACK. 

PRODROMAL  STAGE  (Stadium  Prodromorum),  OR  PERIOD  OF  IN- 
VASION.— The  first  symptoms  are  those  of  an  ordinary  coryza,  with  a 


424  Holt:  "Diseases  of  Infancy  and  Childhood"  (New  York,  1899),  p.  911. 
428  Brown:  Brit.  Med.  Jour.,  April  16,  1887,  p.  826. 

428  Graham:  Article  on  "Measles,"  Morrow's  "System  of  Dermatology,"  etc.  (1894), 
vol.  iii. 


278  THE    ACUTE    EXANTHEMATA. 

watery  discharge  from  the  nose,  sneezing,  lacrymation  and  smarting 
of  the  eyes,  photophobia,  and  irritation  of  the  pharyngeal  and  laryn- 
geal  mucosa,  giving  rise,  in  the  course  of  about  twenty-four  hours, 
to  coughing  and  a  huskiness  of  voice.  With  this  there  is  a  rise  of 
temperature,  usually  from  2  to  3  degrees  during  the  first  day,  which  is 
sometimes  preceded  by  chilliness,  or  more  rarely  by  distinct  rigors  alter- 
nating with  a  feeling  of  heat.  According  to  Ziemssen  and  Krabler,427 
chills  are  rarely  present,  and  in  a  large  number  of  cases  they  observed 
them  in  only  five  instances.  Irritability  and  fretfulness  are  conspicu- 
ous symptoms,  especially  in  children,  or  there  may  be  stupor  and  dull- 
ness of  expression.  Not  infrequently  these  alternate  or  vary  during 
different  hours  of  the  day  and  night.  There  is  usually  a  disagreeable 
taste  in  the  mouth,  and  the  tongue  is  covered  with  a  white  fur,  with 
red,  swollen  papillae  projecting  at  the  margins.  These  latter,  how- 
ever, are  less  conspicuous  than  in  scarlet  fever.  There  is  always  thirst, 
and  the  mouth  and  throat  feel  dry,  with  marked  loss  of  appetite  and 
constipation. 

The  temperature,  which  has  been  exhaustively  studied  by  Wun- 
derlich,428  Thomas,429  and  von  Jiirgensen,430  cannot  be  considered 
characteristic  on  account  of  its  numerous  variations,  and  gives  no  special 
premonition  of  the  nature  of  the  malady.  Unlike  variola,  the  rise  of 
temperature  and  other  symptoms  of  measles  are  of  gradual  develop- 
ment, and,  as  previously  stated,  the  transition  between  the  incubation 
and  prodromal  stages  is  more  or  less  indefinite.  On  the  second  day, 
however,  the  temperature  rises  to  102°,  103°,  or  even  104°  F.  (38.7°, 
39.4°,  40°  C.),  while  on  the  third  day  greater  variability  will  be  ob- 
served. It  is  not  unusual  to  see  the  temperature  descend  nearly  to  the 
normal  at  this  time.  Again,  the  temperature  rises  rapidly  during  the 
first  day  and  gradually  subsides  until  the  appearance  of  the  rash,  when 
in  all  cases  it  rapidly  rises.  Morning  remissions  are,  as  a  rule,  observed. 
During  the  second  day  the  symptoms  usually  increase  in  severity  and 
the  face  becomes  pale  and  puffy,  or  slightly  livid  or  dusky  in  appear- 
ance. The  acrid  nasal  discharge  irritates  the  upper  lip  and  nostrils, 
and  congestive  occlusion  of  the  nares  is  more  or  less  complete.  Xot 


427  Ziemssen  and  Krabler:   "Klinische  Beobachtungcn   tiber  d  e  Maseru   und  ihre 
Complicationen,  u.  s.  w."  Greifswalder  med.  Beitrage,  1861,  B.  2,  S.  117. 

428  Wunderlich :    "Ueber  einige  Verhaltnisse  des   Fieberverlaufes  bei  den   Masern, 
u.  8.  w."    Archiv  der  Heilkunde,  1863,  S.  332. 

429  Thomas:  "Beitrage  zur  Kentniss  der  Masern."     Archiv  der  Heilkunde,  1867. 

430  Von  Jurgensen:  "Masern"  (Wein,  1895),  pp.  80  et  seq. 


RUBEOLA.  Z7y 

infrequently  a  catarrhal  crackling  is  experienced  in  the  Eustachian 
tubes,  and  even  a  slight  deafness  may  be  noticed.  The  palpebral  con- 
junctiva is  injected,  red,  and  cedematous,  while  the  sclerotic  is  trav- 
ersed by  numerous  dilated  capillaries.  This  is  accompanied  by  a 
copious  suffusion  of  the  eyes,  smarting,  and  photophobia.  Naturally 
the  amount  of  discomfort  complained  of  varies  greatly.  Sometimes 
the  prodromal  symptoms  are  so  slight  as  to  escape  notice,  in  which  case 
the  rash  will  be  the  first  symptom  to  attract  attention. 

Moreover,  on  the  morning  of  the  third  day  there  may  be  a  general 
subsidence  of  the  symptoms,  when  the  appetite  returns,  and  convales- 
cence seems  well-nigh  established.  The  respite,  however,  is  usually  of 
short  duration,  for  toward  evening  the  temperature  again  rapidly  rises 
and  the  symptoms  are  renewed  with  increasing  severity.  Thus  far  the 
affection  is  usually  mistaken  for  a  simple  cold,  although  the  cough  is 
hoarse  and  dry  and  partakes  of  a  croupy  character.  There  is  some- 
times a  feeling  of  constriction  about  the  chest,  with  quick  breathing, 
and  wheezing  or  dry  rhonchal  sounds  are  heard.  Auscultation  some- 
times reveals  sibilant  rales  scattered  throughout  the  chest.  The  sub- 
maxillary  and  parotid  glands  are  usually  slightly  enlarged  and  some- 
what tender.  Enlargement  of  the  thyroid  gland  is  likewise  sometimes 
observed.  In  children  slight  delirium  may  be  noticeable  during  the 
evening  of  the  third  day.  Convulsions  are  seldom  encountered  except 
in  extremely  neurotic  subjects.  Epistaxis  is  not  uncommon,  although 
it  is  not  usually  severe.  The  tonsils  are  sometimes  swollen,  of  a  dark- 
red  color,  and  pain  on  deglutition  may  be  complained  of.  Severe 
laryngitis  may  at  this  time  supervene,  and  laryngismus  is  an  alarm- 
ing condition  occasionally  encountered  in  young  children.  At  other 
times  there  is  a  gradual  augmentation  of  the  symptoms  from  day  to 
day. 

If  careful  inspection  of  the  buccal  mucous  membrane  be  made 
during  the  second  and  third  days  of  the  prodromal  stage,  there  will 
be  found  numerous  small  red  spots,  or  maculas,  varying  in  size  from  a 
pin-head  to  a  split  pea;  situated,  for  the  most  part,  on  the  palate, 
uvula,  pillars  of  the  fauces,  and  inner  surface  of  the  cheeks,  and,  less 
frequently,  on  the  third  and  fourth  days,  over  the  entire  buccal  mu- 
cous membrane.  With  a  strong  light  dull-whitish  specks,  0.2  to  0.6 
millimetre  in  diameter,  resembling  minute  vesicles,  may  be  seen  sur- 
mounting these  reddish  maculae.  This  is  generally  considered  to  be 
pathognomonic  of  measles  and  the  first  distinguishing  symptom. 
Nearly  all  clinical  observers  have  noted  the  presence  of  these  premoni- 


280  THE    ACUTE    EXANTHEMATA. 

tory  lesions,  and  their  diagnostic  significance  has  recently  been  em- 
phasized by  Filatow,431  Canby,432  and  Koplik.433 

Like  most  acute  exanthematous  affections,  the  mucous  surfaces 
in  measles  present  the  first  visible  changes  (enanthem).     This  is  ac- 
counted for  by  the  more  delicate  structure  of  the  parts,  as  will  else- 
where be  shown,  and  the  absence  of  a  thick,  horny  epidemic  covering, 
which  masks  the  first  pathological  manifestations  in  the  skin  (exan- 
them).    For  this  reason  the  former  may  be  studied  at  an  earlier  period, 
and,  as  previously  stated,  as  early  as  the  second  day  after  the  appear- 
ance of  constitutional  symptoms.     Even  in  1806  Willan434  observed, 
on  the  fourth  day  of  the  fever,  small,  dark-red  spots  on  the  palate, 
uvula,  and  tonsils,  which  on  the  fifth  day  merged,  forming  a  bright- 
red  surface  extending  backward  to  the  fauces.    In  1812  Heim435  dis- 
tinguished between  the  enanthem  and  exanthem  of  measles.    "Usually 
there  appears  in  the  mouth  on  the  second  day  of  the  fever  small,  bright- 
red  spots  (Kleine  hellrothe  Flecke)"  which  he  regarded  as  identical  with 
those  which  later  appeared  on  the  skin.    In  Dunglison's  "Cyclopaedia 
of  Practical  Medicine"436  (1854),  in  describing  the  eruption  of  measles 
Forbes  states  that  the  eruption  spreads  over  the  face;  spots  also  may 
be  observed  on  the  palate  and  fauces.    Trousseau  in  1866  (loc.  cit.,  p. 
171)  clearly  described  the  early  appearance  of  the  buccal  lesions  and 
their  relation  to  the  subsequent  cutaneous  exanthem.     "Before  there 
is  any  exanthem  on  the  skin  you  see  the  disease  inscribed  on  the 
pharynx,  tonsils,  and  veil  of  the  palate."    Niemeyer437  mentions  that 
Rehn  observed  an  eruption  of  pale-red,  rather  undefined  spots  on  the 
mucous  membrane  of  the  cheeks,  gums,  lips,  and  fauces.    In  addition 
to  these  von  Jiirgensen  (loc.  cit..,  p.  89)  mentions  Franz  Mayr  (1852), 
Ziemssen  and  Krabler  (1861),  Barthez  and  Rilliet  (1854),  and  espe- 
cially Monti  (1873),  as  having  given  particular  attention  to  the  pro- 
dromal enanthem  of  measles.    He  further  quotes  at  length  from  Flindt, 


481  Filatow:  "Acute  Infectionskrankheiten,"  1895,  S.  349. 

442  Canby:  "Notes  sur  l'6nanthSme  buccal  de  la  rouggole;  stomatite  erythemato- 
pultacfie  accompagnant  1'eruption."  Bull  et  Mem.  Soc.  Med.  de  l'H6p.  de  Paris,  1895,  3, 
S.,  xii,  760-762. 

438  Koplik:  Archives  of  Fed.  (New  York,  December,  1896),  and  Med.  Record  (New 
York,  1898),  liii,  505-507. 

*»*  Willan  (Robert):  "Diseases  of  the  Skin"  (London,  1808). 

438  Heim:  Bemerkungen  iiber  die  Verschiedenheit  des  Scharlachs,  der  Rotherln, 
und  der  Masern,  u.  s.  w."  Journal  der  praktischen  Heilkunde,  C.  W.  Hufeland  und  K. 
Hunley,  herausgeber  (1812),  Stuck  iv,  S.  86. 

488  Dunglison :  "Cyclopaedia  of  Practical  Medicine"  (1854),  vol.  iv,  p.  53. 

487  Niemeyer:  "Practice  of  Medicine"  (1876),  vol.  ii,  p.  528. 


PLATE  XXXIV. 


Fiq.l. 


Fiq.  2. 


Fig.  3, 


Fiq.4. 


THE  ENANTHEM,  OR  THE  SO-CALLED  PATHOGNOMONIC  SIGN  OF  MEASLES 

FIG.  i. — The  discrete  measles  spots  on  the  buccal  or  labial  mucous  membrane,  showing  the  isolated  rose- 
red  spot,  with  the  minute  bluish-white  centre,  on  the  skim-milk  colored  mucous  membrane. 

FlG.  2. — Shows  the  partially  diffuse  eruption  on  the  mucous  membrane  of  the  cheeks  and  lips ;  patches  of 
pale  pink  interspersed  among  rose-red  patches,  the  latter  showing  numerous  pale  bluish-white  spots. 

FlG.  3. — The  appearance  of  the  buccal  or  labial  mucous  membrane  when  the  measles  spots  completely 
coalesce  and  give  a  diffuse  redness,  with  the  myriads  of  bluish-white  specks.  The  eocanthema  on  the  skin  is 
at  this  time  generally  fully  developed. 

FlG.  4. — Aphthous  stomatitis  apt  to  be  mistaken  for  measles  spots.  Mucous  membrane  normal  in  color. 
Minute  yellow  points  are  surrounded  by  a  red  area.  Always  discrete. 

(Through  the  courtesy  of  Dr.  Henry  Koplik,  Me't.  News.) 


RUBEOLA.  281 

of  Denmark,  who  in  the  Sundheds-collegium,  1880,  gives  a  clear  ac- 
count of  its  appearance  and  course  as  follows: — 

"First  day  of  the  fever:   A  slight,  diffuse  erythema  of  the  throat. 

"Second  day  of  the  fever:  A  fairly  dark  redness  without  marked 
oedema  of  posterior  pharyngo-palatine  arch  and  tonsils,  which,  on  the 
anterior  palatine  arch  (arcus  glosso-palatinus)  and  velum  palati,  is 
somewhat  less  deep  in  color  and  of  an  irregularly  diffused  or  mottled 
appearance.  On  the  evening  of  the  second  day  of  the  fever  the  mu- 
cous surfaces  of  the  tonsils,  and  the  posterior  palatine  arch,  have  under- 
gone but  little  or  no  change,  appearing  as  a  uniformly  red  erythema, 
with  slight  oedema.  On  the  anterior  surface  of  the  soft  palate,  and  the 
posterior  part  of  the  hard  palate,  as  well  as  occasionally  on  the  remain- 
ing normal  mucous  surfaces,  a  distinct  exanthem  appears.  The  lesions 
are  round  or  irregular  in  shape,  of  a  bright-red  color,  having  an  ill- 
defined  margin,  with  little  or  no  elevation  at  this  time  above  the  sur- 
rounding surface.  They  range  from  a  pin-head  to  a  lentil  in  size,  and 
occur  singly,  or  are  scattered  irregularly  over  the  surface.  In  places 
there  is  a  tendency  for  the  lesions  to  cluster  in  groups  and  to  become 
blended. 

"They  acquire  a  peculiar  appearance  on  account  of  numerous 
small,  white,  glistening  points  (simulating  minute  vesicles),  which  oc- 
cupy the  middle  of  the  small,  red  macules.  These  manifestations  in 
the  macules  are  irregularly  grouped.  One  can  see  and  feel  the  minute 
vesicles  elevated  above  the  surrounding  areas.  The  palpebral  con- 
junctiva is  hyperasmic  in  its  entire  extent.  Besides  the  reticular  and 
macular  reddening  of  the  conjunctiva,  which  is  due  to  the  disposition 
of  the  conjunctiva!  vessels,  there  are  also  small,  glistening,  miliary 
elevations  similar  to  the  elevations  in  the  palate. 

"Third  day  of  the  fever:  The  mucous  surfaces  of  the  buccal  cav- 
ity, which,  up  to  this  time,  have  been  only  slightly  hyperaemic,  are 
now  found  to  be  invaded  by  the  lesions  previously  described.  These 
latter  are  strongly  marked  over  the  entire  anterior  surface  of  the  velum 
palati,  the  glosso-palatine  arch,  and  usually  also  over  the  contiguous 
two-thirds  of  the  hard  palate.  The  red  spots  are  sometimes  very  nu- 
merous, at  other  times  isolated,  and  again,  by  blending,  they  form 
irregular  figures  of  a  stronger  red  than  previously  seen.  Here  and 
there  a  faint  appearance  of  the  previously  described  vesicle-like  forma- 
tions is  seen  projecting  above  the  surrounding  surface.  On  the  other 
hand,  they  may  also  be  found  on  the  apparently  normal  mucous  mem- 
brane. Similarly  grouped  spots  with  whitish  vesicles  now  also  appear 


282  THE    ACUTE    EXANTHEMATA. 

on  the  inner  surface  of  the  cheeks,  especially  on  the  part  opposite  the 
juxtaposition  of  the  upper  and  lower  molar  teeth. 

"As  a  rule,  the  gums  and  the  inner  surface  of  the  lips  retain 
their  normal  color,  or  at  most  are  only  slightly  hyperaemic.  It  is,  in- 
deed, seldom  that  the  eruption  appears  on  these  parts.  The  tonsils  and 
both  pharyngo-palatine  arches  still  remain  red. 

"The  palpebral  conjunctiva  retains  its  deep-red  color,  but  no  spots 
are  visible,  excepting  the  minute  vesicles  previously  described.  At 
this  time  the  eruption  breaks  forth  on  the  skin.  On  the  evening  of 
the  third  day  there  is  little  or  no  change  perceptible. 

"Fourth  day  of  the  fever:  On  the  palate  and  inner  surface  of  the 
cheeks  the  spots  stand  out  prominently,  while  in  many  places  there  is 
a  tendency  to  merge  by  enlargement  of  the  individual  lesions,  and  on 
the  surfaces  last  invaded  they  are  more  copious  than  ever.  The  con- 
junctival  exanthem  is  now  disappearing.  On  the  evening  of  this  day 
there  is  no  change  noted. 

"Fifth  day  of  the  fever:  The  exanthem  in  the  buccal  cavity  is 
more  marked  than  heretofore.  Frequently  at  this  time  there  appear 
faint-reddish  spots  on  the  mucous  surfaces  of  the  lips,  even  extending 
to  the  exposed  cutaneous  margin.  On  the  gums  they  are  seldom  pres- 
ent and  never  distinct.  The  hyperaemia  of  the  posterior  fauces  remains 
unchanged. 

"The  skin  exanthem  begins  to  fade,  and  the  temperature  falls. 

"Sixth  day  of  the  fever:  The  exanthem  on  the  mucous  surfaces  is 
no  longer  visible,  except  a  slight  diffuse  redness  of  the  palate  and  the 
inner  surface  of  the  cheeks.  Fever  ends." 

This  characteristic  enanthem  is  seldom  absent.  Slawyk438  found 
it  present  in  90  per  cent,  of  all  cases  examined. 

Another  symptom  described  by  Bolognini,439  which  he  considers 
pathognomonic  of  measles,  consists  of  a  fine  peritoneal  crepitation,  or 
friction,  "as  if  two  bottles  were  rubbed  together,"  when  the  pulps  of 
the  fingers  are  applied  with  gentle  pressure  to  the  relaxed  abdomen. 
Bolognini  describes  the  method  as  follows:  The  patient  is  placed  on  his 
back,  with  the  legs  flexed  and  the  abdominal  muscle  relaxed.  The 
,pulps  of  the  three  middle  fingers  of  both  hands  are  applied  to  the 
abdomen  and  gentle  pressure,  gradually  increased,  is  made  with  a 
kneading  movement,  when  a  slight  rubbing  sensation  will  be  conveyed 


**»  Slawyk:  Deut.  med.  Woch.,  April  28,  1898. 

**»  Bolognini:  "Jahresbericht  iiber  die  Leistungen  und  Fortschritte  in  der  Gesamm- 
ten  Medicin,"  1898. 


RUBEOLA.  283 

to  the  fingers,  which  disappears  as  the  pressure  is  increased.  Bolognini 
found  this  symptom  absent  in  the  prodromal  stage  only  twice  in  two 
hundred  cases.  It  usually  ceased  with  the  appearance  of  the  cutaneous 
eruption.  He  regards  it  as  due  to  vascular  disturbances  of  the  peri- 
toneum, analogous  to  the  enanthem  as  observed  on  the  mucous  sur- 
faces. Koppen440  found  this  sign  in  50  per  cent,  of  all  cases  examined. 
Little  diagnostic  significance  can  be  attached  to  it,  however,  as  it  is 
now  known  to  be  found  in  other  affections. 

The  duration  of  the  prodromal  stage,  or  stage  of  development,  is 
from  three  to  five  days,  most  frequently  four  days.  In  rare  instances 
this  is  said  by  Trousseau  and  others  to  be  prolonged  to  the  sixth  or 
even  the  tenth  day.  In  270  cases  Holt  (loc.  cit.)  found  the  stage  of 
invasion — that  is,  from  the  beginning  of  the  catarrh  to  the  eruption — 
to  be: — 

1  day  or  less  in  35  cases. 

2  days  "    47       " 

3  "  "    64       " 

4  «  «    64       " 

5  "  "    29  " 

6  "  "    20  " 

7  "  "6  " 

8  "  "      2  " 

9  it  It  o  ft 

& 

10      "  "      1  case. 

Most  of  these  were  under  three  years  of  age.  In  adults  less 
variability  is  observed,  although  Roger441  found  the  period  of  invasion 
shorter  than  in  children  over  two  years  old,  and  longer  than  in  infants. 

PERIOD  OF  EFFLORESCENCE-  (Stadium  Exanthematicum  vel  Flori- 
tianis),  OR  ERUPTIVE  STAGE. — The  eruption  is  usually  first  noticed 
on  the  morning  of  the  fourth  day.  On  the  evening  preceding,  if  care- 
ful inspection  be  made,  a  faint  mottling  or  roughened  condition  of  the 
skin  may  be  detected.  Less  frequently  it  comes  out  on  the  third  or 
fifth  day.  The  first  lesions  appear  on  the  upper  part  of  the  forehead, 
on  the  temples,  behind  the  ears,  and  on  the  sides  of  the  neck.  In 
most  cases  one  or  the  other  of  these  positions  is  first  involved,  although, 
and  more  frequently,  the  eruption  appears  simultaneously  in  one  or 
more  of  them.  It  soon  appears  about  the  eyes,  mouth,  and  on  the  chin. 
At  first  the  lesions  are  few  in  number,  of  a  small,  punctate  appearance, 
dark  reddish  in  color,  presenting  a  clinical  picture  not  unlike  that  pro- 

"°  Koppen :  Ibid. 

««  Roger  (H.):  Rev.  de  Med.,  April,  1900,  p.  290. 


THE    ACUTE    EXANTHEMATA. 

duced  by  fleas  and  other  insects.  With  the  appearance  of  the  exan- 
them  on  the  skin  the  constitutional  disturbances  increase  in  severity, 
the  catarrhal  symptoms  are  aggravated,  the  cough  is  more  trouble- 
some, inspiratory  stridor  may  be  heard,  and  deglutition  is  not  infre- 
quently more  painful.  The  patient  feels  as  if  his  eyes  were  filled  with 
sand,  and  they  are  so  sensitive  to  light  that  some  difficulty  may  even 
be  experienced  in  obtaining  a  clear  view  of  the  eruption  on  the  face. 
It  is  quite  characteristic  to  find  the  patient  with  his  face  buried  among 
the  pillows,  or  to  hear  him  ask  that  the  shades  be  drawn.  The  tem- 
perature at  this  time  is  observed  to  be  rising,  with  slight  morning  re- 
missions, increasing  from  1/2  to  1  degree  toward  the  close  of  day. 
Epistaxis,  although  seldom  severe,  is  frequently  present  in  a  minor 
degree,  sometimes  only  tinging  the  nasal  passages  with  blood.  The 
bowels,  which  have  heretofore  been  constipated,  are  now  not  infre- 
quently excessively  loose,  showing  that  the  lower  digestive  mucosa  is 
likewise  implicated.  In  many  cases  this  is  a  critical  period  and  requires 
careful  attention,  lest,  in  delicate  subjects,  or  when  the  disease  is  un- 
usually severe,  complications  or  some  of  the  various  departures  from 
the  normal  ensue. 

In  a  few  hours  the  punctate  dots  on  the  face  are  observed  to  have 
increased  in  size  as  well  as  in  number.  On  the  second  day  and  some- 
times earlier  the  whole  face  becomes  involved  as  well  as  the  neck, 
upper  part  of  the  chest,  and  back.  At  this  time  it  may  be  observed  that 
the  lesions  tend  to  appear  either  singly  or  in  groups,  in  the  latter  case 
forming  crescents442  or  irregular,  broken  circles.  During  the  first  day 
of  the  eruption  the  lesions  sometimes  assume  a  slight  urticarial  ap- 
pearance, and  are  perceptibly  elevated  above  the  surrounding  skin. 
This  can  more  readily  be  detected  by  the  touch.  More  frequently,  and 
always  after  the  first  day,  the  spots  have  a  soft,  velvety  feel.  Pressure 
with  the  fingers  causes  the  redness  to  momentarily  disappear.  When 
fully  formed  the  lesions  vary  in  size  from  1/24  to  3/8  inch  (1  millimetre 
to  1  centimetre)  in  diameter.  Usually,  however,  they  range  from  1/12 
to  1/8  inch  (2  to  3  millimetres).  They  are  well  defined,  round,  oval, 
or  irregular  in  shape;  of  a  dark-red,  or,  later,  slightly  purplish  color, 
which  in  some  instances  finally  assumes  a  distinct  dusky  or  violaceous 
tint.  This  latter  is  not  infrequently  referred  to  by  the  laity  as  "black 
measles."  The  frequency  with  which  this  is  met  with,  however,  seems 
to  be  less  than  in  former  times,  judging  from  the  description  of  the 
older  writers,  among  whom  may  be  mentioned  Trousseau,  Hebra,  Mor- 

442  Apparently  first  described  by  Willan  (loc.  cit.). 


PLATE  XXXV. 


PLATE  XXXV. 


Rubeola,    showing  the    Eruption    during  the    First    Day. 


RUBEOLA.  285 

ton,  and  Sydenham.  The  skin  between  the  lesions  remains  intact,  al- 
though the  whole  face  has  a  puffy,  cedematous,  sometimes  erythem- 
atous,  appearance. 

The  eruption  extends  over  the  trunk  and  extremities,  including 
the  palms  and  soles,  the  forearms  and  legs  being  the  last  to  become 
affected.  It  is  usually  completed  on  the  evening  of  the  third  or  early 
on  the  fourth  day  of  the  eruption.  With  the  full  development  of  the 
exanthem  the  constitutional  symptoms  subside.  This  is  evidenced  by 
the  degree  of  fever,  rapidity  of  pulse  and  respiration,  as  well  as  the 
catarrhal  symptoms  of  the  upper  mucosa?.  The  temperature,  which  not 
infrequently  attains  a  height  of  104°  or  105°  F.  (40°  to  40.5°  C.), 
now  either  rapidly  falls  (crisis)  or  more  frequently  gradually  subsides 
(lysis);  so  that  in  the  course  of  from  two  to  three  days  the  normal 
bodily  temperature  is  reached. 

Sometimes  a  subnormal  temperature  is  observed  for  some  days,  or 
until  the  patient  regains  his  accustomed  strength.  Even  before  the 
full  development  of  the  lesions  on  the  extremities,  which  are  the  last 
to  appear,  those  first  developed  begin  to  subside.  When  the  eruption 
is  confluent,  this  is  often  preceded  by  a  general  blending  of  the  spots, 
forming  more  or  less  extensive  plaques  of  erythema.  (See  Plate  XL.) 
Usually  the  most  characteristic  lesions  are  found  on  the  trunk  and  espe- 
cially on  the  chest.  About  the  joints  or  between  folds  of  the  skin  the 
eruption  is  always  plentiful  and  the  lesions  often  blend.  In  the  latter 
positions  small  vesicles  sometimes  occur.  The  full  development  of  the 
lesions  on  any  particular  part  is  completed  in  about  twenty-four  to 
thirty-six  hours  after  its  appearance.  On  the  face  pressure  Avith  the 
finger  no  longer  causes  a  complete  disappearance  of  the  redness  as  at 
first  observed,  but  a  slight  yellowish  or  brownish  tint  remains.  The 
bright-livid  color  gradually  fades  to  a  faded  rose  tint  and  the  promi- 
nence of  the  spots  subsides. 

With  the  appearance  of  the  eruption  the  remittent  and  intermit- 
tent character  of  the  fever,  which  we  have  heretofore  observed,  ceases, 
and  there  is  a  more  continuous  elevation  of  temperature  for  two  or  three 
days,  or  until  the  full  development  of  the  cutaneous  exanthem,  when 
it  reaches  the  highest  point.  Thomas443  observed  with  considerable 
regularity  the  maximal  temperature  occurring  at  the  end  of  the  fifth 
or  on  the  sixth  day  after  the  onset  of  the  disease.  It  may  be  remarked 
that  the  maximal  temperature,  and  consequently  the  acme  of  the  dis- 

443  Thomas:  Article  on  "Measles"  in  Ziemssen's  "Cyclopaedia  of  the  Practice  of 
Medicine"  (New  York,  1897),  vol.  ii. 


286 


THE   ACUTE    EXANTHEMATA. 


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URINE 

Chart  of  Severe  Case  of  Measles  ending  in  Recovery  without  Complications. 
(One  of  the  Writer's  Cases.) 


RUBEOLA.  287 

ease,  occurs  with  greater  regularity  than  has  been  shown  to  be  the  case 
in  either  the  prodromal  or  the  eruptive  stage.  The  fever  seldom  ex- 
ceeds 105°  F.  (40.5°  C.),  although  Hunter444  reports  a  temperature 
of  110°  F.  (43.3°  C.)  in  a  child  sixteen  months  old  which  ended  in 
recovery. 

The  catarrhal  symptoms  continue  to  increase  in  severity  with  the 
development  of  the  rash;  the  face  is  often  swollen  and  erythematous 
independently  of  the  eruption;  the  nasal  discharge  becomes  sero-puru- 
lent;  the  cough  is  looser,  with  moist  rales  heard  on  auscultation;  and 
not  infrequently  the  sputum  is  copious  and  of  a  sero-purulent  or  num- 
mular  character.  There  is  usually  some  prostration,  and  the  patient 
prefers  a  recumbent  position.  The  pulse  is  frequent  and  the  breath- 
ing is  short  and  sometimes  labored.  At  this  time  one  should  be  on  the 
lookout  for  bronchitis  or  pneumonia,  which  so  frequently  appear  dur- 
ing this  stage.  Diarrhoea  is  seldom  absent,  even  when  the  bowels  have 
previously  been  unaffected.  The  stools  sometimes  partake  of  a  chol- 
eraic character,  and  pain  in  the  abdomen  may  be  more  or  less  severe. 
Headache  is  sometimes  complained  of,  and  vomiting  has,  though 
rarely,  been  observed.  The  urine  seldom  shows  any  special  changes — 
aside  from  the  diminished  quantity,  deep  color,  and  plentiful  supply 
of  urates  common  to  all  acute  febrile  disorders — until  the  full  develop- 
ment of  the  disease,  when  it  may  show  a  distinct  trace  of  albumin. 
Irritability  of  the  bladder  is  sometimes  present.  The  presence  in  the 
urine  of  epithelial  lining  from  the  urinary  tubules  is  seldom  observed, 
although  hyaline  casts  have  been  reported.  It  may  be  said  further  that 
the  diazo-reaction  was  well  marked  in  two  cases  under  the  author's  care, 
and  that  acetonuria  and  propeptonuria  have  been  reported.  These  ad- 
ventitious products,  however,  have  no  special  prognostic  significance. 
Finally  the  clinician  must  not  lose  sight  of  the  fact  that  the  symptoms 
detailed  are  present  to  a  greater  or  less  degree  in  the  majority  of  cases, 
and  that  no  two  cases  are  exactly  alike.  He  must  expect,  therefore,  to 
find  all  grades  of  severity  and  numerous  variations  in  clinical  appear- 
ance. The  duration  of  this  stage  is  usually  from  four  to  five  days,  more 
rarely  it  is  six  days. 

DECLINE. 

STAGE  OF  DESQUAMATION  (Stadium  Desquamationis},  OR  CON- 
VALESCENT PERIOD. — On  the  second  day  of  the  exanthem  the  catarrhal 


«**  Hunter:  Brit.   Med.  Jour.,  April  30,  1898. 


288  THE    ACUTE    EXANTHEMATA. 

symptoms/together  with  the  oedema  and  eruption  on  the  face,  begin 
to  subside,  and  on  the  following  morning  the  temperature  is  found  to 
be  lower  than  on  the  morning  preceding.  This  is  subject  to  some 
variation,  and  may  take  place  a  day  sooner  or  later.  The  redness  of 
the  various  mucous  surfaces — the  nasal  passages,  buccal  cavity,  and 
conjunctiva? — now  fades  away,  and  there  may  be  at  times  a  slight  des- 
quamation  observed  in  the  mouth.  The  eruption  on  the  skin  of  the 
face,  neck,  and  upper  part  of  the  chest  departs  in  the  order  named,  and 
on  the  fourth  or  fifth  day  of  the  eruption  the  temperature  has  usually 
returned  to  the  normal.  It  may  be  remarked  that  sometimes  a  sub- 
normal temperature  is  observed  for  a  few  days,  which  disappears  as 
the  patient's  appetite  returns  and  strength  is  regained.  The  eyes  are 
less  sensitive  to  light,  free  perspiration  takes  place,  the  tongue  clears, 
the  appetite  returns,  and  on  the  skin  a  slight  branny  desquamation 
takes  place.  This  latter  is  less  marked  than  in  scarlet  fever,  and  on 
the  trunk  and  extremities  may  entirely  escape  notice.  It  is  best  seen 
on  the  sides  of  nose,  temples,  and  chin.  Large,  flaky  scales  are  very 
seldom  observed  in  measles.  After  the  eruption  disappears  a  certain 
amount  of  pigment  remains  for  a  week  or  two  on  the  sites  previously 
involved. 

There  is  usually  some  prostration  still  experienced,  and  the  patient 
is  very  sensitive  to  cold  or  draughts  of  air.  The  coarse  mucous  rales 
now  give  way  to  those  of  a  sibilant  character,  which,  in  turn,  grad- 
ually disappear.  The  duration  of  the  stage  of  efflorescence  is  not  reg- 
ular; usually  it  occupies  from  ten  to  fourteen  days  before  desquama- 
tion is  complete.  It  is  advisable  to  keep  the  patient  within  doors,  or  at 
least  to  guard  him  from  undue  exposure  for  a  week  or  more,  or  from 
three  to  four  weeks  from  the  beginning  of  the  attack. 


RUBEOLA  AXOMALA  ([a]  BENIGNA,  [ft]  MALIGNA). 

ATYPICAL,  OR  ANOMALOUS,  CLINICAL  FORMS. — It  has  been  shown 
that  the  various  symptoms  of  normal  measles  vary  greatly  in  different 
individuals,  and  more  especially  in  different  epidemics;  hence  much 
latitude  must  be  given  to  the  measles  type.  Cases  do,  however,  present 
themselves  in  which  one  or  more  of  the  cardinal  features  are  absent  or 
appear  only  in  a  minor  degree.  Again,  extraneous  conditions  and  com- 
plications, sometimes  arising  from  some  inherent  peculiarity  of  the 
organism,  as  in  rachitis  and  tuberculosis,  may  greatly  influence  the 


PLATE  XXXVI. 


PLATE  XXXVI. 


Rubeoia,    Mild    Form,    showin?   Clustering  of   Lesions  on   Arms. 


HUBEOLA.  289 

general  trend  of  the  disease  or  modify  the  order  of  its  symptoms. 
Finally,  aside  from  these,  the  disease  may  show  unwonted  severity. 
Thus,  we  have  what  may  be  grouped  under  the  head  of  mild  forms, 
and  by  way  of  distinction  those  to  which  the  name  severe  or  even 
malignant  may  be  applied.  Edgar,445  in  an  epidemic  of  423  cases, 
found  only  123  which  adhered  to  the  regular  type. 

MILD  FOKMS. — First  may  be  mentioned  those  cases  in  which  the 
catarrhal  symptoms  are  slight  or  entirely  absent  (morbilli  sine  catarrlw], 
as  in  a  case  reported  by  Harris.446  Usually  in  such  cases  there  are  also 
less  fever  and  other  concomitants  of  the  prodromal  stage  (morbilli  sine 
febre).  At  other  times  the  prodromal  symptoms  may  be  well  marked 
and  the  catarrhal  disturbance  severe,  while  the  cutaneous  exanthem 
is  almost  wholly  absent  (morbilli  sine  morbillis).  Such  cases  may 
readily  be  overlooked  when  they  occur  in  the  absence  of  an  epidemic,  or 
.with  other  well  marked  cases  which  adhere  to  the  usual  type.  The  fre- 
quency with  which  these  anomalies  are  met  with  may  be  inferred  from 
Edgar's  report  previously  referred  to,  in  which,  of  423  cases,  the  only 
constant  symptoms  were  the  rise  of  temperature  and  the  eruption. 
Again,  the  rash  may  appear  as  usual  after  about  four  days  of  pre- 
liminary fever,  but  not  in  the  order  heretofore  observed  nor  to  the 
same  extent.  It  may  appear  on  the  face  only,  or  extend  to  the  trunk 
and  quickly  disappear,  even  before  the  individual  spots  have  time  to 
mature.  Embden447  observed  twenty  cases  of  this  kind  during  an  epi- 
demic at  Heidelberg.  At  other  times  the  regular  form  is  modified  by 
the  very  discrete  distribution  of  the  lesions,  which  appear  only  on  cer- 
tain parts,  as  on  the  extremities  or  trunks,  or  both.  (See  Plate  XXXVI.) 
It  may  further  be  observed  that  they  seldom  become  elevated  or  papu- 
lar, but  remain  macular  and  of  a  pinkish  color.  Frequently  in  these 
cases  the  cutaneous  exanthem  is  not  only  slow  to  appear,  being  delayed 
one  or  more  days,  but  it  manifests  an  equal  tardiness  in  extending  over 
the  body.  One  might  well  be  inclined  to  doubt  the  existence  of  mea- 
sles in  some  of  these  minor  or  abortive  forms  were  it  not  that  they  have 
been  recorded  by  careful  observers,  and  that  such  cases  appear  to  confer 
immunity  to  subsequent  attacks.  The  order  in  which  the  eruption 
appears  is  likewise  subject  to  some  variation.  Mayr448  long  since  called 


445  Edgar:  Canada  Med.  Record,  December,  1892. 
448  Harris:  Lancet,  February  21,  1891. 

447  Embden,  quoted  by  Williams,  Article,  "Measles,"  in  "Twentieth  Century  Prac- 
tice of  Medicine"  (New  York,  1898),  vol.  xiv,  p.  133. 

448  Mayr:  "Morbilli,"  in  Hebra's  "Diseases  of  the  Skin,"  "Sydenham  Society  Trans- 
actions" (London,  1866),  vol.  i,  p.  163. 

19 


290  THE    ACUTE    EXANTHEMATA. 

attention  to  the  fact  that  any  local  irritation — such  as  is  produced  by 
tightly-fitting  bands,  garters,  or  the  application  of  ointments — may  act 
as  a  determining  cause,  the  eruption  appearing  first  on  these  parts. 
He  also  observed  that  paralyzed  regions  or  members  usually  remain 
free.  These  mild  forms  are  said  to  be  most  frequently  observed  at  the 
beginning  and  at  the  end  of  an  epidemic. 

SECOND  ATTACK. — A  relapse  is  said  to  occur  in  rare  instances  after 
the  exanthem  has  disappeared.  This  has  been  observed  most  fre- 
quently about  the  end  of  the  second  week,  and  is  accompanied  by  a 
return  of  the  fever  and,  to  a  less  extent,  of  other  constitutional  symp- 
toms. Cases  of  this  kind  have  appeared  from  time  to  time  in  medical 
literature,  and  recently  they  have  been  observed  by  Lemoine,449 
Sevestre,450  Fischer,451  Vergely,452  Feltz,453  Eoger,454  and  others. 
Measles  recurring  a  few  days  after  apparent  recovery  from  the  first 
attack  has  been  observed  by  Loschner,455  Spiess,456  Lippe,457  and 
others.  Such  a  case  was  seen  recently  in  consultation  by  the  author. 
In  this  instance  there  was  an  interval  of  eight  days  between  the  sub- 
sidence of  the  eruption  and  the  second  efflorescence.  In  both  attacks 
the  usual  symptoms  were  present,  although  the  exanthem  was  best 
marked  in  the  second.  (See  Plate  XXXVIII.)  Fischer  saw  three  sisters, 
aged  one,  four,  and  eight  years,  in  all  of  whom  relapse  occurred  on  the 
ninth,  sixteenth,  and  thirteenth  days,  respectively.  Vergely,  in  the 
case  of  a  girl  ten  years  old,  observed  a  second  attack  of  measles  ten 
days  after  the  efflorescence  of  the  first  attack.  In  this  case  all  of  the 
symptoms,  including  exfoliation,  returned.  Vergely  did  not  regard  it 
as  a  relapse,  but  a  second  attack.  Another  form  of  recurring  measles 
has  been  described  by  Trojanowsky,458  in  which  the  primary  exanthem 
is  said  to  be  slight  and  accompanied  by  high  fever,  which  lasts  about 
six  to  eight  days,  followed  by  an  interval  of  normal  temperature  last- 
ing about  eight  days.  Thomas  regards  this  as  a  form  of  relapsing  fever 
accompanying  measles,  seen  only  in  countries  where  relapsing  fever 
prevails.  On  the  other  hand,  in  an  observation  of  more  than  700  cases 


"•Lemoine:  Bull.  Med.,  January  1  and  8,  1896. 

460  Sevestre:  Ibid. 

461  Fischer:  Correspondenz-bl.  f.  Schw.  Aerzte,  September  15,  1898. 
"2  Vergely:  Rev.  mens.  des  Mai.  de  PEnfance,  August,  1898. 

453  Feltz:  Gaz.  Heb.  de  Med.,  1896,  Nos.  84  and  87. 
4B4  Roger  (H.):  Loc.  cit.,  p.  294. 
*»  Loschner:  "Jahrbuch  f.  Kinderheilk.,"   1868. 

4M  Spiess:   "Frankf.  Jahresber.  Uber  die  Verwalt.  des  Med.  wes.,  Krankenanst.," 
1867,  xi,  p.  40. 

457  Lippe,  cited  by  Thomas. 

448  Trojanowsky:   Dorpat  med.  Ztschr.,  1873,  iii. 


PLATE  XXXVII. 


PLATE  XXXVIII. 


KUBEOLA.  291 

of  measles  reported  by  Camby450  not  a  single  relapse  or  recurrence  was 
seen.. 

While  it  must  be  admitted  such  cases  do  occur,  yet  the  author 
believes,  from  a  study  of  many  cases  in  which  a  secondary  rise  of  tem- 
perature, accompanied  by  a  slight  roseolar  or  macular  eruption  has 
taken  place  during  convalescence  from  measles,  that  many  of  the  so- 
called  relapses  are  due,  in  reality,  to  complications  or  attacks  of  rubella 
rather  than  to  a  direct  reintoxication  by  the  specific  virus. 

SEVEEE,  OR  MALIGNANT,  FORMS. — On  the  other  hand,  the  disease 
may  assume  unwonted  severity,  to  which  the  name  malignant  measles 
is  often  applied.  Of  the  423  cases  reported  by  Edgar,  103  were  of  the 
malignant  type,  having  various  complications,  which  in  7  terminated 
fatally.  This  term,  however,  should  be  used  with  discretion,  as  it  ap- 
plies only  to  infrequent,  isolated  cases  or  to  certain  epidemics.  So  far  as 
the  writer's  observation  goes,  this  latter  is  dependent  upon  debilitating 
causes,  which,  in  turn,  are  due  to  various  extraneous  conditions,  espe- 
cially such  as  relate  to  hygiene  and  exposure  to  excessive  heat  or  cold. 
The  influences  pertaining  to  camp  life  and  large  armies  often  act  as 
predisposing  causes;  hence  the  name  "camp  measles"  sometimes  ap- 
plied to  this  form.  Again,  the  period  of  efflorescence  may  be  modified 
and  the  eruption  appear  well-nigh  simultaneously  over  the  whole  body. 
Such  cases  are  usually  accompanied  by  high  fever  and  an  aggravation 
of  the  symptoms  of  the  eruptive  stage.  As  a  rule,  however,  the  erup- 
tion is  of  shorter  duration,  and  the  concomitant  symptoms  more 
quickly  subside  than  in  the  normal  type.  Neither  can  this  form  be 
considered  especially  malignant,  as  the  anomaly  does  not  apparently 
influence  the  death-rate.  This  form  occurs  more  commonly  in  children 
than  in  adults.  There  is  another  form  in  which  the  eruption  rapidly 
recedes  soon  after  its  appearance.  When  the  fever  and  other  symptoms 
subside  pari  passu,  the  case  is  liable  to  terminate  favorably;  but  with 
the  continuation  of  a  high  temperature,  rapid  pulse,  and  labored 
breathing  and  great  prostration,  death  is  liable  to  supervene.  The 
fatal  issue  most  frequently  occurs  on  the  second  day  of  the  exanthem. 
The  retrocession  of  the  eruption  is  not  the  cause  of  the  unfavorable 
course,  as  commonly  supposed,  but  is  dependent  on  the  severity  of  the 
disease,  or  more  properly  the  active  involvement  of  the  internal  organs. 
Great  apprehension  was  shown  at  one  time  lest  the  eruption  "strike 
in,"  and  the  laity  still  manifests  great  satisfaction  on  seeing  "the  dis- 
ease come  out." 


459  Camby:  Ibid. 


292  THE    ACUTE    EXANTHEMATA. 

In  certain  epidemics,  especially  when  occurring  in  crowded  or 
ill-conditioned  institutions,  measles  may  present  what  is  called  the 
TYPHOID  OR  ATAXIC  FORM.  Such  cases  not  infrequently  occur  among 
troops  after  a  long  period  of  exposure,  or  during  a  siege  in  time  of  war. 
In  these  cases  the  constitutional  symptoms  soon  take  on  an  alarming 
character,  accompanied  by  a  rapid  rise  of  temperature,  104°  to  105° 
F.  (40.0°  to  40.5°  C.),  and  a  frequent,  compressible  pulse,  which  in 
children  attains  a  rapidity  of  130  to  145  beats  per  minute.  The  res- 
pirations are  likewise  rapid,  usually  varying  from  50  to  80.  The  mouth 
becomes  parched,  the  tongue  dry,  and  the  lips  cracked.  The  bowels 
are  loose  and  the  quantity  of  urine  is  always  greatly  diminished.  The 
nerve-centres  are  profoundly  impressed  by  the  specific  toxin,  and  re- 
peated convulsions  are  not  uncommon  in  children,  while  in  adults 
delirium,  either  low  or  boisterous  and  violent,  is  sometimes  observed. 
This  is  followed  by  great  prostration,  and  the  patient  not  infrequently 
passes  into  a  comatose  stage,  which  terminates  in  death.  This  is  most 
liable  to  occur  on  the  third  or  fourth  day  of  the  eruption.  At  other 
times  these  symptoms  subside,  and  the  case  subsequently  follows  a  pro- 
tracted, though  otherwise  normal,  course,  which  leads  to  recovery. 

In  other  cases  the  respiratory  organs  are  severely  attacked,  giving 
rise  to  dyspnoea  even  during  the  prodromal  stage,  and  as  the  eruption 
appears  tHe  difficulty  in  breathing  becomes  more  marked.  This  is 
called  the  SUFFOCATIVE  FORM,  and  is  accompanied  by  frequent  cough- 
ing of  a  hacking  character,  accompanied  by  expectoration  of  frothy 
mucus.  The  dyspnrea  is  especially  troublesome  and  sometimes  the  pa- 
tient becomes  rapidly  cyanotic.  Mucous  rales  are  heard  at  an  early 
stage,  which  in  unfavorable  cases  rapidly  increase  in  number.  When 
the  first  onset  is  survived,  such  cases  usually  terminate  in  capillary 
bronchitis;  and  especially  is  this  true  of  children.  The  immediate 
cause  of  death  is  usually  ascribed  to  heart-failure,  while  in  adults  death 
more  frequently  is  due  to  syncope.  In  common  with  all  grave  compli- 
cations of  the  viscera,  the  eruption  is  scanty  and  liable  to  fade  away 
soon  after  its  appearance. 

Finally  we  have  the  H^EMORRHAGIC  FORMS  (morbilll  hcemorrhagica], 
"black  measles,"  of  which  there  are  two  varieties.  Under  the  first  may 
be  included  those  cases  of  a  mild  nature  in  which  the  ha?morrhage  has 
little  influence  on  the  course  of  the  disease  and  which  usually  ter- 
minate favorably.  The  second  applies  to  unusually  severe  or  malig- 
nant cases  in  which  the  hemorrhage  often  greatly  intensifies  the 
original  disease  and  from  which  the  patient  seldom  recovers. 


RUBEOLA.  293 

The  MILD  FORM  of  haemorrhagic  measles  is  not  of  infrequent  oc- 
currence. Holt  (loc.  cit.,  p.  915)  found  it  in  5  per  cent,  of  all  cases. 
Edgar  (loc.  cit.),  during  an  epidemic  of  423  cases,  found  200  cases,  or 
47  per  cent.,  of  the  haemorrhagic  form.  Its  frequency,  however,  is  sub- 
ject to  great  variation,  and  it  is  more  common  in  some  epidemics  than 
in  others. 

Usually  there  is  no  premonition  given,  the  appearance  of  the  dis- 
coloration being  the  first  symptom  to  attract  attention.  The  cutaneous 
exanthem  assumes  a  dark-bluish  or  purplish  tint,  which  gradually 
deepens,  as  the  process  continues,  to  a  bluish-black  color.  It  does  not 
disappear  on  pressure.  Sometimes  the  discoloration  is  confined  to  the 
macula?,  at  other  times  numerous  specks,  or  petechiae,  varying  from  a 
pin-head  to  a  lentil  in  size,  appear  in  the  sound  integument  between 
the  lesions  of  the  exanthem.  In  distribution  the  extravasations  like- 
wise vary  greatly  in  different  cases.  The  lower  extremities  alone  may 
be  involved,  or  the  trunk  may  be  invaded,  while  the  arms,  neck,  and 
head  remain  free.  More  frequently  the  whole  body  shows  a  general 
tendency  to  bleed.  The  mucous  surfaces  are  implicated  in  like  manner, 
giving  rise  to  epistaxis,  bleeding  from  the  gums,  dysenteric  stools,  and 
haemorrhage  from  the  genito-urinary  tract.  With  the  subsidence  of 
the  efflorescence  the  haemorrhagic  areas  assume  a  yellowish  tint,  and 
in  the  course  of  a  week  or  ten  days  gradually  disappear.  Convalescence 
from  this  form  is  somewhat  prolonged,  otherwise  the  normal  course  of 
the  disease  is  usually  maintained.  At  other  times  the  general  symp- 
toms are  severe,  being  not  infrequently  accompanied  by  severe  nausea 
and  vomiting.  Dysenteric  stools  are  seldom  absent,  and  in  young  chil- 
dren this  form  frequently  leads  to  broncho-pneumonia  and  death.  In 
adults,  or  when  occurring  in  well  nourished  subjects,  the  presence  of 
haemorrhage  does  not,  to  any  great  extent,  influence  the  mortality  of 
the  disease. 

The  MALIGNANT  FORM,  which  seems  to  have  been  so  widely  prev- 
alent during  the  eighteenth  century,  is  now  seldom  encountered.  The 
severity  of  the  disease  is  dependent  largely  on  the  condition  of  the 
patient  previous  to  the  attack  and  the  hygienic  conditions  in  which 
he  lives.  Those  who  are  prone  to  haemorrhagic  extravasations,  haem- 
ophilic  subjects  or  "bleeders,"  are,  of  course,  especially  predisposed. 
Again,  children  under  three  years  of  age  who  are  confined  within 
doors,  or  live  in  crowded  or  unwholesome  asylums  and  foundling 
hospitals,  furnish  a  large  contingent  of  these  cases. 

Unlike  the  preceding  variety,  the  malignant  form  greatly  influ- 


294  THE   ACUTE    EXANTHEMATA. 

ences  the  course  and  termination  of  the  disease.  It  may  be  ushered  in 
by  severe  epistaxis  during  the  prodromal  period,  in  which  case  there  is 
no  primary  remission  of  the  fever  during  this  stage,  and  with  the  ap- 
pearance of  the  rash  the  severity  of  the  symptoms  increases  with  alarm- 
ing rapidity.  Xor  does  the  exanthem  appear  in  the  order  observed  in 
the  normal  type.  Xot  infrequently  there  is  a  more  or  less  complete 
retrocession  of  the  rash  during  the  first  or  second  day.  This  is  accom- 
panied by  great  prostration,  twitching  of  the  muscles,  and  sometimes 
involuntary  evacuation.  During  this  time  the  rash  takes  on  a  blue- 
violet,  livid,  or  black  color,  or  there  appear  petechiae,  vibices,  and  purple 
blotches  or  ecchyrnoses  on  various  parts  of  the  body.  Blood  oozes  from 
the  gums,  the  sputum  is  tinged  with  blood,  blood  is  discharged  from 
the  bowels,  or  the  evacuations  are  tarry  in  color  and  the  urine  is  mixed 
with  blood.  AVith  this  the  pulse  is  compressible,  weak,  and  rapid;  the 
respirations  are  hurried;  and  the  patient  sinks  into  a  profound  collapse. 
Death  may  take  place  at  any  time,  and  usually  occurs  within  forty- 
eight  hours  after  the  onset  of  the  haemorrhagic  symptoms. 
Between  these  extremes  all  grades  of  severity  exist. 

COMPLICATIONS  AND  SEQUELAE. 

The  complications  of  measles  are,  on  account  of  their  frequency 
and  fatality,  by  far  the  most  important  features  to  bear  in  mind  in 
considering  this  subject.  In  60  cases  of  measles  Haig  Brown  (loc.  cit.) 
found  complications  and  sequelae  in  48,  and  absent  in  only  12  cases. 
As  will  be  shown,  they  may  appear  at  any  stage,  and  sometimes  the 
symptoms  to  which  they  give  rise  completely  mask  or  supersede  those 
of  the  original  disease.  Again,  they  give  rise  to  grave  conditions  which 
continue  for  an  indefinite  period  and  are  known  as  sequelae. 

The  Skin. — The  early  cutaneous  concomitants  of  measles  are  of 
importance  mainly  from  a  diagnostic  point  of  view,  as  they  have  a  very 
limited  influence  on  the  course  of  the  disease.  It  has  been  shown  that 
erythema  often  appears  during  the  prodromal  stage,  and  in  this  feature 
measles  bears  some  resemblance  to  variola  and  scarlet  fever.  More 
frequently  it  supervenes  during  the  stage  of  efflorescence,  when  for  the 
most  part  it  is  limited  to  the  face,  neck,  and  upper  part  of  the  trunk. 
It  is  of  short  duration  and  fades  away  with  the  full  development  of  the 
exanthem. 

In  young  children,  as  a  result  of  free  perspiration,  miliary  vesicles 
are  sometimes  observed.  They  are,  in  reality,  sudamina,  and  appear 
on  parts  plentifully  furnished  with  sudoriparous  glands,  as  the  neck, 


RUBEOLA.  295 

axillae,  and  inner  surface  of  the  thighs,  and  more  especially  when  these 
surfaces  are  thickly  covered  with  the  rash.  This  sometimes  gives  rise 
to  itching,  and  may  lead  to  an  error  in  diagnosis;  but  further  than  this 
sudamina  are  of  little  importance  and  do  not  affect  the  regular  course 
of  the  disease.  From  the  wide-spread  vascular  disturbance  in  the  skin 
one  would  naturally  look  for  certain  inflammatory  complications  of 
the  integument  during  an  attack  of  measles.  This  not  infrequently  is 
the  case,  although  they  are,  for  the  most  part,  of  a  mild  nature  which 
do  not  call  for  special  consideration.  Eczema  is  sometimes  observed, 
and  in  those  specially  predisposed  it  may  persist  long  after  the  efflores- 
cence which  gave  rise  to  it  has  disappeared.  Psoriasis  likewise  has  been 
known  to  make  its  first  appearance  during  the  desquamative  stage,  or 
soon  after  the  disappearance  of  measles,  although  we  have  no  ground 
for  believing  that  in  such  cases  measles  acts  otherwise  than  as  an  ex- 
citing cause  in  a  predisposed  subject. 

From  the  disrupted  condition  of  the  cuticle,  extraneous  pathog- 
enic organisms  readily  gain  access  to  the  underlying  structures  of  the 
skin;  hence  the  appearance  of  the  coccogenous  dermatoses,  such  as 
impetigo,  furunculosis,  and  plilegmonous  abscesses.  These  are  met  with 
far  less  frequently  in  measles  than  in  variola,  and  seldom  lead  to  the 
extensive  suppurations  so  common  in  the  latter  disease. 

Cases  of  measles  accompanied  by  a  buttons  eruption  resembling 
pemphigus  have  been  reported  by  Du  Castel,460  Krieg,  and  Loschner,461 
and  quite  recently  by  Baginsky.462  In  one  case  Baginsky  found  diplo- 
cocci,  in  another  the  streptococcus  pyogenes  was  found.  Both  cases 
terminated  fatally.  These  are  probably  instances  of  the  bullous  form 
of  impetigo. 

Cases  of  cutaneous  tuberculosis  following  measles  have  been  re- 
ported by  Du  Castel,463  Haushalter,464  and  Adamson.465  According  to 
Du  Castel,  cutaneous  tuberculosis  more  frequently  follows  measles  than 
is  generally  supposed.  It  is  usually  widely  disseminated,  and  attacks 
the  face,  upper  extremities,  and,  to  a  less  degree,  the  trunk  and  legs. 
At  first  it  appears  in  the  form  of  small  nodules  of  a  deep-red  color. 
Later  it  may  present  larger  patches  varying  from  a  dime  to  a  quarter 
dollar  in  size,  which  are  apparently  formed  by  the  union  of  the  original 


480  Du  Castel:  Rev.  g6n.  de  din.  et  de  Therap.   (Paris,  1897),  xi,  p.  609. 

481  Quoted  by  Thomas  (foe.  cit.). 

482  Baginsky:  Archiv  f.  Kinderh.,  H.  1  and  11,  B.  28,  1900. 

493  Du  Castel:  Annal.  de  Derm,  et  de  Syph.,  1898,  tome  ix,  Nos.  8  and  9,  p.  729. 

484  Haushalter:  Annal.  de  Derm,  et  de  Syph.,  1898,  tome  ix,  No.  5,  p.  455. 

485  Adamson:   Brit.   Jour,   of  Derm.,   1899,   p.   20. 


296  THE   ACUTE    EXANTHEMATA. 

nodules.  They  appear  very  soon  after  the  measles  eruption  and  rapidly 
attain  their  full  development,  when  they  remain  with  little  or  no 
change  for  a  long  time.  A  few  lesions  show  a  tendency  to  spontaneous 
resorption,  leaving,  in  some  instances,  the  characteristic  lupous  cica- 
trix.  In  the  two  cases  reported  by  Haushalter  inoculation  of  guinea- 
pigs  with  portions  of  the  lesions  gave  rise  to  tuberculosis  in  these  ani- 
mals. 

The  early  implication  of  the  nerve-centres,  which  sometimes  oc- 
curs in  measles,  favors  the  development  of  certain  dermatoses  which  are 
ascribed  either  to  reflex  disturbances  or  to  an  irritation  in  some  portion 
of  the  nervous  tract.  Among  the  most  conspicuous  are  urticaria  and 
herpes.  In  the  author's  experience,  the  former  is  the  more  common, 
and  apparently  is  due  to  a  reflex  disturbance  arising  from  peripheral 
irritation  in  the  digestive  tract.  In  two  cases  Claus486  reports  urticaria 
occurring  during  the  incubative  stage  of  measles.  In  herpes  the  face 
is  the  part  most  frequently  involved  (herpes  facialis).  Thomas  (loc. 
cit.)  mentions  zoster  femoralis  occurring  in  connection  with  measles. 

Mucous  Membranes.  —  Of  all  structures  none  show  greater  sus- 
ceptibility than  the  mucous  membranes  to  the  virus  of  measles.  Xot 
only  do  the  characteristic  lesions  first  appear  on  them,  but  they  furnish 
the  nidus  for  by  far  the  most  serious  complications.  In  this  two  main 
factors  may  be  recognized:  First,  the  natural  tissue  resistance,  or  the 
vis  medicatrix  natural  of  the  older  writers;  and,  second,  the  invasion 
and  subsequent  development  of  pathogenic  micro-organisms.  The  mu- 
cous surfaces  in  measles  present  a  favorable  culture  medium  for  the 
growth  and  development  of  bacteria  of  various  degrees  of  virulence. 
This  is  especially  so  in  debilitated  subjects,  or  when  the  secretions  are 
allowed  to  remain  and  accumulate  within  the  body.  As  to  the  second 
factor,  it  is  quite  generally  known  that  in  health  various  micro-organ- 
isms— such  as  the  pneumococcus,  the  streptococcus  pyogenes,  and  the 
staphylococcus  pyogenes  aureus — are  found  in  the  mucous  secretions 
of  the  respiratory  tract  without  producing  any  ill  effects.  Kyle467 
found  the  bacillus  of  diphtheria  on  the  nasal  mucous  membrane  after 
inhaling  the  air  of  a  diphtheritic  ward,  and  the  bacillus  of  tuberculosis 
after  the  individual  had  been  exposed  to  the  dusty  air  of  the  street. 
In  health,  or  more  properly,  when  the  physiological  resistance  of  the 
structures  is  maintained,  these  are  innocuous.  It  is  only  when  a  suit- 


*••  Claus:  Jahrb.  f.  Kinderh.  u.  phys.  Erzieh.,  June  5,  1894. 
*"7Kyle:  "Diseases  of  the  Nose  and  Throat"   (Philadelphia,  1899). 


BUBEOLA.  297 

able  soil  is  found  that  they  proliferate  and  develop  the  virulence  pecul- 
iar to  each. 

The  Eyes. — Although  the  eyes  suffer  less  frequently  than  in 
variola,  yet,  in  common  with  the  other  mucous  surfaces,  the  congestive 
disturbance  of  the  conjunctivas  in  measles  at  -times  sets  up  severe  in- 
flammatory and  destructive  changes.  In  scrofulous  children  a  profuse 
blennophthalmia  is  not  infrequent,  which  leads  to  abscesses  of  the  con- 
junctiva or  keratitis,  resulting  when  neglected  in  ulceration  of  the 
cornea  and  a  train  of  other  misfortunes,  such  as  perforation  or  de- 
structive panophthalmitis,  which  so  frequently  follows.  When  the 
cornea  is  involved,  there  is  always  extreme  sensitiveness  to  light. 
Again,  in  more  favorable  cases  the  lids  alone  are  involved,  when  we 
may  have  phlyctenular  ulcers,  blepharitis,  abscesses  at  the  ciliary  mar- 
gin, and,  finally,  granulation  of  the  lids. 

The  Ears. — The  catarrhal  inflammation  of  the  Eustachian  tube 
and  cavity  of  the  middle  ear  offers  conditions  favorable  to  the  develop- 
ment of  various  pathogenic  organisms,  such  as  the  staphylococcus  albus 
and  aureus,  and  in  some  instances  to  the  streptococcus  pyogenes. 
When  the  patient  is  in  a  recumbent  position  the  free  escape  of  the 
augmented  secretion  becomes  retarded,  resulting  in  the  development 
of  highly  virulent  and  infective  pus.  This  condition,  which  is  spoken 
of  under  the  general  term  otitis,  is,  next  to  the  laryngeal  and  pulmonary 
disturbances  to  be  described,  the  most  serious  of  all  the  complications 
of  measles. 

Its  insidious  development  from  the  usual  congestive  disturbances 
previously  described  may  escape  notice  until  extensive  suppuration  has 
taken  place.  At  other  times  the  patient  complains  of  pain  in  the  ear, 
or  sometimes  there  is  great  restlessness,  grinding  of  the  teeth,  sudden 
cries  in  children,  and  delirium  in  adults.  The  first  indication  may  be 
a  sudden  rise  of  temperature,  which  should  always  put  one  on  guard 
against  some  serious  complication.  In  very  young  children  its  location 
may  not  easily  be  determined,  rendering  the  diagnosis  at  first  largely 
conjectural.  In  most  cases  it  appears  about  the  end  of  the  second 
week  of  the  disease,  although,  as  pointed  out  by  Tobeitz,468  it  may  be 
recognized  post-mortem  as  early  as  the  first  day  of  the  cutaneous  erup- 
tion and  is  usually  well  marked  by  the  fourth  day.  In  addition  to  the 
pain  complained  of,  loss  of  hearing  may  soon  be  detected,  when  an  ex- 
amination often  reveals  evidences  of  inflammation  about  the  margin 


488  Quoted  by  Williams  (loc.  cit.). 


298  THE    ACUTE    EXANTHEMATA. 

of  the  tympanic  membrane,  which  is  lustreless,  and,  if  extensive  sup- 
puration be  present,  a  yellowish  discoloration  may  be  detected  at  its 
most  dependent  segment.  If  the  process  continue,  bulging  of  the 
tympanum  may  be  observed,  with  subsequent  rupture  of  this  mem- 
brane. This  is  a  fortunate  occurrence,  as  it  relieves  the  pent-up  sero- 
purulent  accumulation  and  thus  prevents  its  extension  to  more  vital 
parts.  Bezold409  found  post-mortem  in  16  cases  of  otitis  media  the 
tympanic  cavity  filled  with  muco-pus,  which  in  some  instances  had  ex- 
tended to  the  antrum  and,  when  sufficiently  developed,  to  the  mastoid 
cells.  In  one  instance  the  osseous  portion  of  the  Eustachian  tube  was 
involved,  and  in  all  there  was  marked  congestion  of  the  mucous  mem- 
brane of  the  cavities  of  the  ear,  with  numerous  hemorrhages. 

Unfortunately,  the  early  occlusion  of  the  Eustachian  tube  prevents 
the  escape  of  the  purulent  contents  of  the  aural  cavity,  and  when  no 
external  exit  is  found  a  fatal  issue  is  imminent.  For  this  reason,  in 
severe  forms  the  suppurative  process  may  extend  to  the  antrum,  and 
Bezold  (loc.  cit.)  found  the  mastoid  cells  likewise  involved,  leading  to 
meningitis,  cerebral  abscess,  and  pyaemia.  This  cerebral  extension  is 
facilitated  in  early  childhood  by  the  petromastoid  suture,  which  at  this 
time  is  still  patent,  allowing  free  access  of  pus  into  the  cranial  cavity 
from  the  middle  ear. 

Downie470  in  501  cases  of  tympanic  involvement  found  that  131, 
or  26.1  per  cent.,  were  due  to  measles.  In  more  advanced  life  the  most 
vulnerable  point  is  the  tegmen  tympani,  which  is  not  only  perforated 
by  numerous  foramina  for  vascular  anastomosis,  but  separates  the  attic 
portion  of  the  tympanum  from  the  brain  by  a  very  thin  and  fragile 
layer  of  bone. 

The  cerebral  extension  is  sometimes  announced  by  the  patient 
falling  into  a  comatose  state,  from  which,  unless  prompt  means  are 
taken,  he  may  not  rally.  The  absence  of  definite  and  pathognomonic 
symptoms  of  otitis,  together  with  the  importance  of  its  early  recog- 
nition, render  it  imperative  that  the  greatest  care  be  taken  in  the  man- 
agement of  measles  to  guard  against  and,  when  present,  to  mitigate  the 
serious  consequences  of  this  complication. 

This  condition  not  infrequently  leads  to  permanent  impairment  of 
hearing  or  actual  deafness,  although  in  the  author's  experience  less 
frequently  than  in  scarlet  fever.  Of  487  children  admitted  to  the  Ohio 


*••  Bezold:  MUnchener  med.  Woch.,  1896,  Nos.  10  and  11. 
470  Downie:  Brit.  Med.  Jour.,  1894,  vol.  ii,  p.  1163. 


EUBEOLA.  299 

Institute  for  the  Education  of  the  Deaf  and  Dumb,  14  gave  measles  as 
the  cause  of  deafness,  while  in  47  it  was  attributed  to  scarlet  fever. 

In  Great  Britain,  according  to  Kerr,  Love,  and  Addison,471  of 
1410  deaf-mutes,  138,  or  about  9.8  per  cent.,  attributed  their  deafness 
to  measles.  Statistics  of  deaf-mutism  collected  by  the  same  writers 
in  American  institutions  show:  of  1673  cases,  52,  or  3.1  per  cent., 
attributed  their  loss  of  hearing  to  measles,  and,  of  1989  cases  collected 
in  the  continental  countries  of  Europe,  84,  or  4.2  per  cent.,  were 
attributed  to  the  same  cause. 

The  Respiratory  Tract. — Measles,  in  common  with  the  other  exan- 
themata, is  always  a  serious  disease  in  strumous  children.  Chronic 
congestion  of  the  upper  respiratory  tract  and  the  tendency  to  tuber- 
culosis of  the  pulmonary  structures  are  among  the  contingencies  to  be 
feared,  and  when  these  already  exist,  even  in  their  incipiency,  they  are 
always  greatly  aggravated  by  the  catarrhal  prodrome  of  measles. 

The  Larynx. — Among  the  more  frequent  and  serious  complica- 
tions of  measles  in  young  children  is  laryngitis,  of  which  there  are 
three  forms.  The  first  variety,  the  spasmodic,  sometimes  called  false 
croup,  is  most  commonly  met  with  in  infants  or  precocious  children, 
and  is  accompanied  by  a  very  moderate  degree  of  inflammation,  but 
with  a  strong  tendency  to  muscular  spasm.  The  cough  is  frequent,  dry, 
and  barking,  or  spasmodic  in  character,  sometimes  incessant;  and  a 
whistling  respiratory  sound  may  be  audible  at  some  distance.  Suffoca- 
tive  spasms  may  also  occur  in  attempting  to  drink.  This  form  usually 
subsides  as  the  cutaneous  eruption  reaches  full  maturity.  The  second 
form,  acute  phlegmonous  laryngitis,  is  characterized  by  severe  inflam- 
mation, which  gives  rise  to  increased  hoarseness,  and  in  some  instances 
the  patient  is  unable  to  speak  aloud.  Movements  in  attempting  to 
speak  or  palpation  from  without  causes  pain.  In  such  cases  the  expec- 
toration frequently  becomes  stained  with  blood.  Ulceration  and  ex- 
tensive gangrene  sometimes  follow,  and  even  necrosis  of  the  cartilages 
and  destruction  of  the  vocal  cords  have  been  observed.  Cough  is  less 
troublesome,  and  often  is  entirely  absent  in  this  form.  A  dangerous 
complication  at  this  time  is  oedema  of  the  glottis,  which,  if  not  re- 
lieved, may  cause  death  in  a  few  hours.  Fortunately,  however,  this  is 
rarely  met  with. 

The  third  form  is  one  of  the  most  fatal  complications  of  measles, 
and  is  characterized  bv  the  formation  of  a  whitish  membrane  on  the 


471  "Deaf-mutism:  A  Clinical  and  Pathological  Study"  (Glasgow,  1896). 


300  THE    ACUTE    EXANTHEMATA. 

laryngeal  surfaces.  This  is  supposed  to  be  due  to  a  streptococcus 
(which  is  identical  in  microscopical  appearance  with  that  found  in 
erysipelas  and  suppuration)  giving  rise  to  a  highly  coagulable  albu- 
minous exudate.  Membranous  laryngitis,  or  croup,  associated  with 
measles,  occurs,  for  the  most  part,  in  large  foundling  institutions  where 
children  are  congregated  and  where  the  rules  of  hygiene  are  not  strictly 
adhered  to.  Children  under  three  years  of  age  are  especially  liable  to 
this  form.  It  appears  during  the  eruptive  stage,  as  early  as  the  third 
or  fourth  day,  or  it  may  set  in  at  any  time  up  to  the  second  week  after 
the  appearance  of  the  eruption.  It  is  usually  accompanied  by  a  dry, 
shrill  cough.  The  voice  takes  on  a  whispering  character,  and  the  false 
membrane  may  extend  upward  to  the  fauces  and  tonsils,  or  downward 
into  the  trachea.  Dyspnoea  is  usually  marked,  occurring  at  first  in 
paroxysms,  which  gradually  become  more  and  more  frequent  until 
asphyxia  ensues.  At  other  times  there  is  little  warning  of  approach- 
ing asphyxia  until  the  struggle  for  breath  occurs,  which  frequently  ter- 
minates in  death  from  exhaustion.  In  1'Hospice  des  Enfants  Assistes 
Granlou,472  in  an  observation  of  1633  cases  of  measles,  found  mem- 
branous laryngitis  occur  235  times,  of  which  218  proved  fatal;  whereas, 
among  the  remaining  1398  cases  in  which  this  complication  was  absent, 
only  388  died. 

Diphtheria. — Some  difference  of  opinion  exists  as  to  the  nature  of 
membranous  laryngitis  and  its  relation,  if  there  be  any,  to  diphtheria. 
Without  entering  into  the  discussion  of  a  subject  more  properly  treated 
of  in  other  works,  it  may  be  said  that  membranous  laryngitis  is  prob- 
ably due  to  pyogenic  cocci,  while  the  Klebs-Loeffler  bacillus  is  now  gen- 
erally accepted  as  the  specific  contagium  of  diphtheria.  The  latter 
disease  may  also  occur  in  connection  with  measles.  It  is  far  more  in- 
fectious, however,  and  the  fever  and  general  constitutional  symptoms 
are  characterized  by  greater  severity  than  is  usually  observed  in  croup. 
In  an  epidemic  of  96  cases  reported  by  Adriance473  in  the  Nursery  and 
Child's  Hospital,  of  New  York,  36  were  complicated  with  diphtheria, 
4  of  which  proved  fatal. 

The  Lungs. — The  tracheo-bronchial  catarrh  which  is  recognized 
as  one  of  the  common  disturbances  of  measles  sometimes  goes  beyond 
the  limit  ascribed  to  it  as  normal,  and  either  by  its  severity  or  dire 
consequences  entirely  supersedes  in  importance  the  original  disease. 
It  is  a  matter  of  common  observation  that  all  are  not  equally  predis- 

472  Granlou:  "La  Rugeole  a  1'Hospice  des  Enfants  Assistes"  (Paris,  1892),  IV. 
478  Adriance:  Archives  of  Fed.,  Feb.,  1900. 


RUBEOLA.  301 

posed  to  pulmonary  complications.  This  applies  in  like  manner  to 
other  complications  of  measles;  in  fact,  in  private  families  the  death- 
rate  in  some  epidemics  is  less  than  1  per  cent.,  while  in  the  Hospice  des 
Enfants  Assistes  in  Paris  the  death-rate  during  the  three  years  pre- 
ceding 1885  reached  the  appalling  fatality  of  4-1  per  cent.,  of  which 
secondary  infection  of  the  lungs  furnished,  by  far,  the  greatest  num- 
ber. On  improving  the  hygienic  conditions  in  this  hospital,  especially 
those  relating  to  sunlight  and  ventilation,  it  has  been  found  possible  to 
reduce  the  fatality  of  measles  one-half.  It  may  be  readily  understood, 
therefore,  that  delicate  or  rachitic  children,  or  others  predisposed  to 
bronchitis,  are  especially  susceptible  during  an  attack  of  measles  to 
the  pulmonary  complications  herein  to  be  considered. 

It  has  been  shown  that  many  pathogenic  cocci  and  bacilli,  as  well 
as  numerous  unclassified  non-pathogenic  germs,  are  found  on  the  mu- 
cous surfaces  of  the  respiratory  tract.  It  has  also  been  shown  that  the 
catarrhal  disturbances  peculiar  to  measles  offer  a  fertile  field  for  their 
further  development,  which  accounts  for  the  frequency  of  tracheitis 
and  bronchitis  to  a  greater  or  less  extent.  While  admitting  that  in  the 
great  majority  of  cases  these  affections  pass  away  without  serious  conse- 
quences, yet,  at  times,  bronchitis,  especially,  assumes  a  more  virulent 
character^  either  by  extension  from  the  larynx  or  from  its  development 
in  loco,  when  it  must  be  considered  a  complication  of  no  little  impor- 
tance. In  strumous  young  subjects  who  have  not  yet  passed  the  second 
decennium  the  trachea  and  larger  bronchial  tubes  are  often  involved  in 
a  subacute  inflammation  which  is  characterized  by  a  profuse  sero-puru- 
lent  expectoration.  This  may  continue  long  after  the  disease  which 
gave  rise  to  it  has  disappeared,  and  not  infrequently  leads  to  tubercu- 
losis of  the  lungs.  This  variety  is  sometimes  spoken  of  as  plilegmonous 
bronchitis. 

A  more  serious  complication  consists  in  the  involvement  of  the 
smaller  ramifications  of  the  bronchial  tubes,  giving  rise  to  capillary 
bronchitis.  This  is  one  of  the  most  serious  complications  of  measles. 
It  usually  occurs  during  the  period  of  efflorescence,  and  may  be  recog- 
nized by  a  continued  rise  of  temperature  when  the  cutaneous  exanthem 
has  begun  to  subside,  or  by  a  chill  followed  by  fever,  headache,  and 
vomiting.  With  these  there  is  an  aggravation  of  the  cough  and  res- 
piration becomes  frequent  and  more  labored.  The  patient  soon  shows 
signs  of  deficient  blood-aeration,  and  alarming  dyspnoea  and  adynamic 
symptoms  rapidly  follow.  It  is  usually  of  general  distribution,  in- 
volving one  or  both  lungs.  The  physical  symptoms  are  the  same  as 


302  THE    ACUTE    EXANTHEMATA. 

observed  in  capillary  bronchitis  when  measles  is  not  present.  At  first 
sibilant  rales  are  widely  distributed,  followed  by  moist  rales,  which 
become  especially  wheezing  on  expiration.  There  is  usually  a  feeble 
respiratory  murmur,  and  the  resonance  on  percussion  is  sometimes 
slightly  increased. 

Broncho-pneumonia.  —  The  most  fatal  as  well  as  the  most  fre- 
quent complication  of  measles  is  broncho-pneumonia.  Houl474  en- 
countered it  in  one-fifth  of  all  cases.  In  two  epidemics  embracing  300 
cases  in  the  Nursery  and  Child's  Hospital,  New  York,  Holt475  observed 
it  in  40  per  cent,  of  all  cases,  of  which  70  per  cent,  proved  fatal.  Its 
prevalence  is  especially  marked  in  foundling  institutions  and  asylums, 
and  it  is  directly  due  to  the,  development  of  various  organisms,  of  which 
the  pneumococcus  of  Friedliinder  and  the  micrococcus  pneumonia?  of 
Frankel  play  a  conspicuous  role.  When  this  complication  supervenes 
the  eruption  rapidly  subsides;  there  may  or  may  not  be  a  chill  or 
repeated  rigors,  but  the  temperature  always  rises,  and  the  pulse,  at  first 
full  and  incompressible,  soon  becomes  weak,  small,  yielding,  and  irreg- 
ular. It  is  always  greatly  accelerated.  Eespiration  is  short  and  fre- 
quent, the  cough  is  hacking,  often  spasmodic  and  difficult  to  repress, 
and  the  usual  signs  of  pneumonia  with  marked  prostration  become  rap- 
idly developed.  The  physical  examination  reveals  at  first  rhonchi  and^ 
widely  disseminated  subcrepitant  rales,  which  soon  give  way  to  de- 
ficient resonance,  bronchial  breathing,  and  fine  crepitations.  This 
complication  may  arise  as  early  as  the  first  day  of  the  exanthem,  or 
more  rarely  as  late  as  the  second  week.  In  young  children  its  onset 
is  acute,  with  rapid  pulmonary  congestion,  and  usually  terminates 
fatally  within  two  or  three  days.  In  older  children  or  adults  the  affec- 
tion of  the  lungs  usually  pursues  a  more  subacute  course,  is  more  fre- 
quently of  the  lobar  variety,  and  sometimes  leads  to  the  so-called 
caseous  pneumonia,  or  phthisis  pulmonalis. 

The  Digestive  Tract. — The  mucous  membranes  of  the  digestive 
tract  are  nearly  always  involved  to  a  greater  or  less  extent  in  measles. 
Stomatitis  not  infrequently  follows  the  congestive  disturbance  of  the 
mouth  which  has  been  shown  to  be  one  of  the  constant  symptoms  of 
the  disease.  While  it  seldom  gives  rise  to  serious  consequences,  its 
presence  cannot  be  wholly  ignored.  As  in  other  mucous  surfaces  the 
condition  offers  a  suitable  soil  for  the  development  of  numerous  micro- 
organisms. The  regions  most  commonly  involved  are  the  sulci  be- 

474  Houl:  Wiener  klin.  Rund.,  1897,  vol.  xi,  p.  833. 
476  Holt  Uoc.  cit.). 


RUBEOLA.  303 

tween  the  cheek  and  gums.  The  process  may  remain  limited  or  extend 
to  contiguous  parts.  At  first  whitish  patches  form,  which  soon  become 
denuded  of  epithelium,  giving  rise  to  superficial  ulcers,  which  extend 
both  at  the  periphery  and  in  depth.  In  this  way  the  destructive  process 
may  continue  until  large  areas  are  destroyed,  and  in  rare  instances  this 
eventuates  in  severe  ulcerative  stomatitis.  Almost  pure  cultures  of  the 
staphylococcus  aureus  have  been  obtained  from  these  lesions.  More 
frequently  they  are  superficial  and  of  short  duration,  subsiding  with, 
or  soon  after,  the  disappearance  of  the  rash. 

In  other  cases  the  usual  catarrhal  symptoms  do  not  subside  upon 
the  disappearance  of  the  cutaneous  eruption.  On  the  contrary,  either 
a  subacute  or  chronic  inflammation  ensues,  giving  rise  to  redness,  swell- 
ing, and  pain  on  deglutition.  The  tonsils,  especially,  are  prone  to  in- 
crease in  size,  and  not  infrequently  suppuration  takes  place,  either  in 
the  follicles,  when  the  discharge  wells  up  from  numerous  openings 
(acute  lacunar  tonsillitis),  or  by  the  formation  of  a  single  abscess-cavity 
(parenchymatous  or  acute  circumtonsillar  inflammation).  One  or  both 
tonsils  may  be  involved.  The  process  may  extend  to  the  stomach,  giv- 
ing rise  to  nausea,  pain,  and  vomiting  of  blood.  Somewhat  more  fre- 
quently the  intestines  are  affected  in  like  manner,  and  diarrhoea,  which 
has  previously  been  noted,  becomes  aggravated.  This  condition  may 
continue  long  after  the  disappearance  of  the  exanthem. 

Koger476  reports  secondary  infection  from  the  intestinal  tract, 
giving  rise  to  phlegmonous  hepatitis,  perihepatitis,  and  pleurisy. 

The  Nervous  System. — The  frequency  of  disturbances  of  the  nerv- 
ous system  associated  with  measles  varies  greatly,  and  seems  to  depend 
more  on  individual  peculiarity  than  on  the  severity  of  the  attack. 
While  the  nerve-centres  are  more  or  less  impressed  in  all  cases,  it  is 
very  seldom  that  any  serious  complication  occurs.  Cioffi477  has  ad- 
vanced the  theory  that  the  measles  toxin  has  a  marked  effect  on  the 
vagus,  and  that,  when  severe,  it  at  first  irritates,  then  paralyzes,  it. 
This  is  confirmed  by  others,  and  some  maintain  that  the  frequency  of 
the  various  catarrhal  conditions,  and  especially  purulent  otitis,  depend 
on  an  irritation  of  the  meningeal  branches  of  the  vagus,  which  at  first 
gives  rise  to  the  catarrhal  symptoms,  and  which,  in  turn,  predisposes 
to  simple  and  tubercular  phlogistic  affections.  Of  the  more  important 
the  following  may  be  mentioned: — 

Disseminated  Myelitis. — This  infrequent  complication  of  measles 

478  Roger:  Presse  M£d.,  Paris,  1897,  ii,  pp.  189  and  192. 
477  Cioffl,  Riforma  Med.,  1900,  51  to  53. 


304  THE   ACUTE    EXANTHEMATA. 

usually  makes  its  appearance  at  an  early  stage  of  the  exanthem.  It 
gives  rise  to  stupor,  loss  of  control  over  the  sphincters,  difficulty  in 
swallowing,  slowness  of  speech,  and  inco-ordination,  leading  to  paraly- 
sis, which  is  wide-spread  and  which  may  not  disappear  with  the  sub- 
sidence of  the  active  period  of  the  disease.  Cases  have  been  reported 
by  Barlow478  and  Williams479  in  which  the  post-mortem  examination 
revealed  vascular  disturbances  of  the  cord. 

Hemiplegia. — Many  cases  of  hemiplegia  have  been  reported,  al- 
though, for  the  most  part,  they  have  not  been  of  a  serious  nature,  and 
in  the  vast  majority  of  cases  recovery  has  taken  place.  Lop480  divides 
all  paralyses  following  or  associated  with  measles  into  two  main  forms: 
the  cerebral,  or  those  arising  from  changes  in  the  brain,  and  the  spinal, 
or  those  due  to  disturbances  in  the  cord.  Hemiplegia  is  found  less  fre- 
quently associated  with  measles,  however,  than  with  scarlet  fever.  Of 
120  cases  of  hemiplegia  observed  by  Osier,481  4  appeared  soon  after  an 
attack  of  measles  and  7  followed  scarlet  fever.  In  80  cases  of  hemi- 
plegia reported  by  Gowers482  7  were  after  measles  and  7  followed  scar- 
let fever.  Hemiplegia,  however,  is  more  often  a  sequela  than  a  com- 
plication of  measles.  Of  9  cases  mentioned  by  Williams,  the  paralysis 
appeared  during  the  height  of  the  disease  in  4  cases,  while  in  4  others 
it  occurred  during  convalescence,  and  in  1  the  time  of  appearance  is 
not  stated.  It  may,  therefore,  appear  as  early  as  the  first  or  second 
day,  or  as  late  as  the  third  week  of  the  disease.  In  most  cases  it  has 
been  observed  to  follow  soon  after  an  attack  of  convulsions,  or  a  series 
of  attacks  in  which  the  spasms  may  be  general  or  limited  to  the  side 
in  which  paralysis  takes  place.  More  cases  have  occurred  in  females 
than  in  males. 

False  disseminated  sclerosis  is  sometimes  observed  during  an  at- 
tack of  measles,  especially  when  accompanied  by  high  pyrexia.  Cases 
have  been  reported  in  which  the*symptoms  pointed  to  acute  ascending 
paralysis  resembling  very  closely  that  observed  in  other  acute  infec- 
tious diseases  accompanied  by  high  temperature,  and  which  is  usually 
characterized  by  its  rapid  development  followed  by  loss  of  conscious- 
ness from  which  the  patient  may  not  rally.  If  consciousness  be  re- 
gained it  is  often  found  that  the  patient  is  aphasic  and  gives  mani- 


478  Barlow:  "Trans.  Medico-Chir.  Soc.,"  vol.  Ixx,  p.  77. 

479  Williams  (Dawson):  "Trans.  Medico-Chir.  Soc.,"  vol.  Ixxvii,  p.  57. 
180  Lop:  Centralb.  f.  klin.  Med.r  1893,  No.  50. 

481  Osier:   "The  Cerebral  Palsies  of  Children"   (London,  1889). 

482  Gowers:  "Manual  of  Diseases  of  the  Nervous  System"   (London,  1888),  vol.  it, 
p.  423. 


RUBEOLA.  305 

festations  of  extensive  paralysis,  paresis,  or  even  ataxia.  Even  these 
do  not  necessarily  imply  a  fatal  termination,  and  the  patient  may  com- 
pletely recover  therefrom.  They  sometimes,  however,  give  way  to  a 
condition  resembling  disseminated  sclerosis  which  differs  essentially 
from  the  true  disseminated  sclerosis  in  that  the  symptoms  are  retro- 
gressive rather  than  progressive,  and  more  especially  tend  to  recovery. 
AVilliams  reports  paralysis  of  the  soft  palate,  pharynx,  and  tongue,  as 
well  as  the  muscles  of  the  neck,  which  in  4  cases  appeared  during  the 
•earliest  days  of  the  disease  and  in  4  others  after  three  weeks.  In  all 
cases  recovery  took  place  in  from  three  to  twenty  days.  In  cases  re- 
ported by  Barthez  and  Senne483  paralytic  symptoms  appeared  during 
the  first  few  days  of  the  disease,  while  in  other  cases  they  were  observed 
as  sequelae  three  weeks  after  the  disappearance  of  the  measles.  Of  these 
cases  all  recovered.  There  is  sometimes  permanent  impairment  of  the 
muscles  of  the  throat,  especially  those  relating  to  deglutition  and 
phonation.  Williams  refers  to  this  class  of  affections  under  four  head- 
ings, namely: — 

(a)  Acute  disseminated  myelitis. 

(6)  Cases  presenting  at  a  later  date  symptoms  resembling  dis- 
seminated sclerosis  (false  disseminated  sclerosis). 

(c)  Cases  in  which,  with  some  symptoms  similar  to  those  of  the 
preceding  group,  the  most  prominent  symptom  is  inco-ordination. 

(d)  Cases  of  "extensive,  ascending,  diffuse,  or  disseminated"  paral- 
ysis, resembling  diphtherial  paralysis. 

Tetany  is  sometimes  met  with  during  an  attack  of  measles  in  very 
young  children  or  infants.  This  more  frequently  occurs  when  there 
has  previously  been  a  tendency  to  convulsions. 

Muscular  Atrophy. — This  sometimes  appears  as  a  sequela  to  paral- 
ysis following  measles.  Holmes  Coote484  reports  a  case  of  muscular 
atrophy  following  measles  which  gave  rise  to  talipes  equinus.  In  a  case 
reported  by  Ormerod485  the  father  and  two  children  were  affected 
with  muscular  atrophy  following  measles. 

Chorea  is  sometimes  given  among  the  less  frequent  sequelae  of 
measles.  Of  439  cases  of  chorea  collected  by  Stephen  Mackenzie,486 
measles  is  recorded  as  an  antecedent  in  116  cases,  or  26  per  cent.  Of 
these  it  was  the  sole  antecedent  illness  in  32  cases,  or  7  per  cent.  These 

483  Rilliet  and   Barthez:    "Traite'   cliniq.    et  pratiq.   des  mal.    des   enfants"    (Paris, 
1891),  tome  iii,  p.  38. 

484  Coote,  quoted  by  Williams  (loc.  cit.),  p.  151. 

488  Ormerod  (J.  A.):  Brain  (London,  1885),  p.  335,  vol.  vii. 
486  Mackenzie:  Brit.  Med.  Jour.,  Feb.  26,  1887,  pp.  425  et  seq. 


306  THE   ACUTE    EXANTHEMATA. 

statistics,  which  on  account  of  the  care  taken  in  their  compilation  are 
of  the  highest  value,  fail  to  show  any  definite  etiological  relation  be- 
tween measles  and  chorea. 

Mental  Disorder. — Sometimes  measles  gives  rise  to  an  apathetic 
condition  which  may,  under  strong  predisposing  influences,  become 
permanent.  In  an  analysis  of  2000  cases  of  idiocy  made  by  Beach,487 
37,  or  1.85  per  cent.,  followed  an  attack  of  one  of  the  acute  exan- 
themata, of  which  number  measles  furnished  11,  or  over  30  per  cent. 
It  may  be  stated  further  that,  in  the  majority  of  cases  supposed  to  be 
due  to  the  eruptive  fevers,  there  was  also  a  history  of  insanity,  im- 
becility, epilepsy,  convulsions,  etc.,  in  the  parents  or  other  members 
of  the  family.  Finkelstein488  has  reported  two  cases  of  acute  mania 
during  measles,  and  Bond488  observed  acute  mania  on  the  eighth  day 
of  measles. 

The  Heart. — Structural  changes  in  the  heart  must  be  conceded 
to  be  among  the  very  rare  complications  of  measles.  That  the  heart- 
muscle  is  weakened  during  a  severe  attack  of  measles  as  in  other  high 
pyrexias  is  a  matter  of  common  observation,  and  death  may  take  place 
from  what  is  commonly  called  "heart-failure."  According  to  Williams, 
fatty  degeneration  has  been  found  post-mortem  in  cases  in  which  the 
first  sound  had  been  toneless  and  in  some  instances  had  been  accom- 
panied by  a  systolic  murmur.  Endocarditis  has  been  known  to  make  its 
first  appearance  during  the  course  of  measles.  Such  cases  have  been 
reported  by  J.  Hanley  Hutchinson,490  Cheadle,491  and  others.  In  159 
cases  of  measles  Haig  Brown  (loc.  cit.}  observed  endocarditis  in  1  case 
and  pericarditis  with  effusion  in  1  case.  The  author  is  in  accord  with 
Stephen  Mackenzie,492  Lee,493  and  Sturges,494  who  believe  that  the  few 
cases  on  record  do  not  show  any  evidence  that  measles,  per  se,  induces 
heart  disease. 

The  Kidneys. — As  in  most  acute  febrile  diseases,  albuminuria  is 
sometimes  found  in  rubeola.  It  is,  however,  less  common  than  in 
scarlet  fever,  and  seldom,  leads  to  any  serious  consequences.  Loeb405 
reports  propeptonuria  present  in  9  out  of  12  cases  examined  during 


487  Beach  (Fletcher):  Brit.  Med.  Jour.,  1895,  vol.  ii,  p.  707. 
4S»  Finkelstein  (I.  M.):   Vrach,  No.  20,  1898. 
489  Bond:  Maryland  Med.  Jour.,  Jan.  29,  1898. 

90  Hutchinson  (J.  Hanley):  "Trans.  Medico-Chir.  Soc.,"  1891,  vol.  Ixxiv,  p.  229. 

91  Cheadle:  Ibid. 

92  Mackenzie,  Stephen  (loc.  cit.,  p.  429). 

93  Lee:  "Trans.  Medico-Chir.  Soc.,"  vol.  Ixxiv,  1891,  pp.  229  et  seg. 

94  Sturges:  "Trans.  Medico-Chir.  Soc.,"  vol.  Ixxiv,  1891,  pp.  229  et  seq. 
96  Loeb,  quoted  by  Dawson  Williams  (loc.  cit.). 


RUBEOLA.  307 

the  height  of  the  disease  or  at  the  beginning  of  desquamation.  A  fatal 
case  of  uraemia  following  measles  is  reported  by  Zichy-Woinarski.496 
Ascites  and  general  anasarca  are  sometimes  observed  even  when  the 
heart  and  kidneys  seem  to  be  normal. 

Aside  from  the  complications  implicating  important  organs, 
measles  sometimes  gives  rise  to  certain  other  conditions  of  a  more  gen- 
eral character.  Tuberculosis  of  the  lungs  following  pneumonia  has 
already  been  sufficiently  dwelt  upon,  but  measles  not  infrequently  is 
followed  by  tuberculosis  of  the  lymphatic  glands  as  well  as  of  other 
structures,  giving  rise  to  the  ordinary  symptoms  of  marked  struma. 
In  those  predisposed  the  utmost  care  should  be  exercised  in  obviating 
this  condition. 

Pur  pur  a  has  likewise  been  encountered,  the  two  cutaneous  mani- 
festations remaining  distinct  throughout.  More  frequently  when  pur- 
pura  supervenes  it  modifies  the  exanthem,  constituting  the  haemor- 
rhagic  form  of  measles  previously  considered. 

Phlebitis  following  an  attack  of  measles  has  been  reported  by 
Mackey,497  of  the  Children's  Hospital,  Brighton,  England.  This  case 
terminated  fatally. 

Gangrene. — When  the  tissue  resistance  is  feeble,  as  in  strumous 
subjects,  gangrene  of  various  organs  may  be  encountered  as  a  sequela 
of  measles.  Mery  and  Lorrain498  observed  extensive  gangrene  of  the 
lung  in  measles  in  which  there  were  found,  in  the  gangrenous  focus, 
streptococci,  a  bacillus  resembling  the  Klebs-Loeffler  bacillus,  bacilli 
which  morphologically  resembled  the  streptothrix,  and  a  large  putre- 
factive germ.  Cancrum  oris,  or  noma,  has  also  been  reported  by 
Rotch,499  and  vulvitis  leading  to  extensive  gangrene  of  the  part  has 
also  been  encountered.  Wunder500  reports  a  case  of  extensive  gangrene 
in  the  wall  of  the  thorax  following  measles. 

Measles  may  co-exist  with  other  diseases.  When  it  attacks  a  pa- 
tient with  psoriasis  or  chronic  eczema  it  not  infrequently  causes  the 
chronic  eruption  to  disappear.  This  usually  returns,  however,  after 
the  acute  exanthem  has  passed  away.  Measles  and  scarlet  fever  have 
been  observed  together  by  Himowitch,501  Johnston,502  and  others; 


496  Zichy-Woinarski:  Australian  Med.  Gaz.,  Oct.  15,  1893. 

497  Mackey:  Brit.  Med.  Jour.,  Dec.  19,  1896,  p.  1772. 

498  Mery  and  Lorrain:  Anat.  de  Paris,  March,  1897. 
4TORotch:  Pediatrics,  1896,  p.  587. 

500  Wunder:  Miinchener  med.  Woch.,  1897,  xliv,  536. 

501  Himowitch:  Med.  Record,  Sept.  7,  1895. 

602  Johnston:  Brit.  Med.  Jour.,  Dec.  31,  1898,  p.  1928. 


308  THE   ACUTE    EXANTHEMATA. 

measles  and  chicken-pox  by  Joshua.503  In  these  acute  affections  mea- 
sles usually  appears  after  the  original  disease  has  well-nigh  disappeared. 
There  seems  to  be  a  special  tendency  to  simultaneous  occurrence  of 
measles  and  pertussis.  Bernardy504  observed  it  twenty-one  times  in 
166  cases. 

Subcutaneous  emphysema  complicating  measles  has  been  reported 
by  Kelly,505  Felsenthal,506  and  Palleske.507  In  these  cases  there  was 
an  absence  of  severe  cough  or  any  known  injury. 

Pregnancy  associated  with  measles  predisposes  to  premature  de- 
livery, ha?morrhage,  and  a  septic  condition.  It  is  far  less  serious,  how- 
ever, than  when  accompanying  variola,  and  it  is  said  that  the  lying-in 
woman  is  less  susceptible  to  the  disease  than  others.  Pregnancy,  it 
must  be  understood,  offers  no  safeguard  against  the  contraction  of 
measles.  As  this  disease  usually  occurs  in  early  youth,  it  is  seldom 
that  the  parturient  state  calls  for  more  extensive  consideration. 

PATHOLOGY. 

Mucous  Membranes. — The  anatomical  changes  in  measles  are  first 
observed  in  the  mucous  membranes,  and  are  usually  limited  to  the 
"conjunctiva?,  nose,  pharynx,  larynx,  and  the  larger  bronchial  tubes. 
The  changes  here  correspond  to  those  commonly  found  in  ordinary  ca- 
tarrhal  inflammation.  The  secretions  at  first  are  transparent,  although 
they  soon  become  opaque,  and,  according  to  Mayr,508  are  always  of 
alkaline  reaction.  The  earliest  pathognomonic  disturbances  of  measles 
consist  in  a  dilatation  of  the  capillaries  and  venous  radicals  in  the 
"buccal  mucous  membrane,  giving  rise  to  a  light-bluish  tint,  or 
•"skimmed-milk  color,"  which  is  followed,  within  twenty-four  to  forty- 
-eight  hours,  by  the  dark-red  spots  previously  described.  These  corre- 
spond in  the  main  to  those  subsequently  observed  on  the  skin,  except- 
ing that  on  the  mucosa  they  are  less  sharply  defined,  and  the  con- 
gested vessels  gradually  blend  with  the  surrounding  vascular  net-work. 
In  an  histological  study  of  the  early  mucous  lesions  in  the  mouth 
Slawyk  (loc.  cit.)  found  the  epithelial  cells  thickened  and  in  some 
instances  they  had  undergone  fatty  degeneration,  giving  rise  to  the 


603  Joshua:  Lancet,  July  13,  1889. 

604  Bernardy:  Annals  of  Gyn.  and  Fed.,  July,  1894. 
^Kelley  (S.  W.):  Therap.  Gaz.,  Jan.,  1891. 

"•  Felsenthal:  Archlv  f.  Kinderh.,  B.  14,  H.  1  and  2,  1891. 
507  Palleske:  Deut.  med.  Woch.,  1898,  vol.  xxiv,  p.  255. 

808  Mayr:    Article,   "Measles,"  in  Hebra's  "Diseases  of  the  Skin,"  New  Sydenham 
Society  (London,  1866),  vol.  i,  p.  177. 


RUBEOLA.  309 

whitish  dots  or  vesicular  appearance  previously  referred  to.  As  yet  no 
special  micro-organisms  have  been  found  in  the  lesions.  Sometimes  a 
more  active  destructive  process  ensues,  which  begins  in  the  lymphatic 
follicles  and  is  supposed  to  be  due  to  the  intensity  of  the  inflammatory 
changes.  This  may  go  on  to  the  formation  of  ulcers  which  frequently 
extend  to  the  deeper  parts.  Similar  changes  have  been  found  in  the 
intestinal  mucous  membrane,  usually  involving  the  lymph-follicles  and 
Peyer's  patches.  Gerhardt509  found  lesions  similar  to  those  observed 
in  the  buccal  mucous  membrane  in  the  larynx  and  trachea  after  death. 
Steiner,  following  Thomas  and  Bohn,510  describes  reddish  spots  on  the 
mucous  surface  of  the  intestines,  which  have  some  resemblance  to  the 
cutaneous  exanthem.  Yon  Jiirgensen  cites  Fuchs  and  others  as  hav- 
ing found  similar  changes  in  the  mucous  surfaces  of  the  genito-urinary 
tract. 

The  Skin. — The  first  macroscopical  appearance  of  the  exanthem 
occurs  abo'ut  the  hair  sacs  and  follicular  apertures,  which  sometimes 
become  raised  above  the  level  of  the  skin,  forming  minute  papules. 
In  some  instances  vesicles  appear  at  these  points,  which  are  due  to  the 
closure  of  the  apertures  of  the  coil-glands.  Sometimes  a  number  of 
papules  occur  close  together.  Accompanying  these  changes  there  is  a 
superficial  congestion  of  the  surrounding  integument,  which  presents 
a  well  defined  margin  quite  unlike  that  observed  in  the  inflammatory 
halo  of  chicken-pox.  This  sharp  line  of  demarkation,  according  to 
Mayr  (loc.  cit.,  p.  177),  is  due  to  the  cutaneous  furrows  which  limit  the 
capillary  injection.  When  the  macules  are  of  large  size,  they  are 
formed  by  the  coalescence  of  smaller  ones.  Anatomical  changes  in 
the  skin  correspond  to  those  observed  in  acute  hyperamia  accompanied 
by  exudation,  the  latter  giving  rise  to  cedema,  which  may  be  limited 
to  the  individual  lesions  or  appear  as  a  diffuse  swelling  of  the  skin. 

These  changes  are  first  observed  in  the  papillae,  and  later  may 
extend  to  the  deeper  layers  of  the  derma.  Venous  congestion  gives 
rise  to  the  cyanotic  appearance  usually  observed,  and  the  papillary 
oedema  may  account  for  the  urticarial  appearance  sometimes  seen  dur- 
ing an  early  stage  of  the  exanthem.  Unna511  has  called  attention  to  the 
evanescent  anatomical  changes  which  soon  disappear  during  life,  and 
show  no  marked  post-mortem  alterations.  In  this  respect  it  differs 
from  that  observed  in  scarlet  fever.  At  the  same  time  marked  evi- 


609  Gerhardt  (Carl):  "Lehrbuch  der  Kinderk."  (Tubingen,  1871),  p.  94. 

610  Quoted  by  von -Jiirgensen  (loc.  cit.,  p.  94). 

611  Unna:  Orth's  "Pathological  Anatomy"  (1894),  pp.  627  and  628. 


310  THE    ACUTE    EXANTHEMATA. 

dences  of  oedema  are  sometimes  present.  As  the  exudate  travels  in 
the  direction  of  least  resistance,  it  is  observed,  especially  in  early  life, 
in  fatty  tissue,  about  the  coil-glands,  sebaceous  glands,  and  muscles  of 
the  skin,  as  well  as  about  the  hair  follicles.  According  to  this  ob- 
server, it  is  not  uncommon  to  find  an  individual  coil-gland,  hair  bulb, 
or  a  small  cutaneous  muscle  appearing  free  in  these  dilated  spaces. 
Besides  this,  one  finds  in  the  under  and  middle  portions  of  the  skin 
oval  or  irregular  cavities,  which  appear  to  be  enlarged  lymph-spaces. 
Aside  from  these  well  marked  changes  there  is,  to  a  less  extent,  oedema 
of  the  subcutaneous  structure.  The  migration  of  white  blood-corpus- 
cles is  not  greater  than  observed  in  simple  hyperaemia  from  other 
causes;  in  fact,  it  is  less  marked  than  in  many.  Few  leucocytes  are 
found  in  the  epidermis.  The  prickle-cell  layer  is  not  thickened,  nor 
does  the  oedema  extend  to  the  interspinous  spaces  of  this  layer.  Unna 
has  never  observed  mitosis  at  the  acme  of  the  process,  but  believes  it 
first  appears  during  the  stage  of  desquamation.  On  the  other  hand, 
there  appears  a  slight  anomalous  keratosis,  in  which  the  stratum  granu- 
losum  gradually  disappears,  while  the  basal  horny  layer  becomes  corre- 
spondingly thickened.  During  the  period  of  desquamation  the  super- 
basal  cells  of  the  horny  layer  become  separated  from  the  basement-layer 
of  the  stratum  corneum,  which  with  the  middle  and  uppermost  cells 
becomes  detached,  thus  completing  the  process  of*  desquamation.  With 
this  mitosis  begins,  resulting  in  the  regeneration  of  the  cells  thus  de- 
stroyed. Catrin512  has  observed  a  marked  diapedesis  of  the  white 
blood-cells  in  the  papillae,  while  Neuman513  noted  round-cell  prolifera- 
tion, especially  well  marked  about  the  blood-vessels,  follicles,  and  coil- 
glands.  The  former  likewise  mentions  a  colloid  degeneration  of  the 
deeper  strata  of  the  epidermis,  which  first  appears  in  the  perinuclear 
zone. 

In  a  peculiar  eruption  which  developed  in  a  patient  recovering 
from  measles  Unna514  found  the  eruption  bore  a  close  similarity  in 
anatomical  structure  to  that  of  small-pox.  No  involvement  of  the 
epidermis  was  found,  but  the  eruption  was  supposed  to  be  caused  by 
the  presence  of  bacteria  in  the  capillaries  of  the  papillary  layer  of  the 
derma.  Unna  has  further  called  attention  to  thrombosis  of  the  super- 
ficial vessels  of  the  skin  in  measles  due  to  the  same  cause,  which  may 

512  Catrin:  "Les  alterations  de  la  peau  dans  la  rougeole."  Archiv.  de  Med.  experi- 
ment., 1891,  No.  2. 

BIS  Neuman:  "Histolog.  Veranderungen  der  Haut  bet  Masern  u.  Scharlach." 
"Med.  Jahrb.,"  1882,  p.  159. 

su  Unna:  Univ.  Med.  Jour.,  Oct.,  1895. 


RUBEOLA.  311 

occur  without  haemorrhage.  In  post-mortem  examinations  in  which 
gangrene  has  occurred  streptococci  have  heen  invariably  present. 

The  Blood. — Xo  uniform  or  important  changes  in  the  blood  have 
been  found  in  measles.  In  severe  cases  it  has  been  observed  by  some 
to  be  post-mortem  of  a  bluish  or  brownish-red  color,  while  others 
affitm  that  it  seldom  completely  coagulates.  In  other  cases  after  death 
it  has  been  observed  to  become  thick  and  tarry;  again  thin,  and  of 
a  cherry-red  tint.  Widowitz515  in  eighteen  cases  of  measles  found  the 
haemoglobin  diminished  as  the  fever  subsided.  In  most  cases  it  in- 
creased in  quantity  during  convalescence,  until  it  equaled  that  found 
during  the  height  of  the  fever.  According  to  Franz,516  the  haemo- 
globin, as  determined  by  Gowers's  method,  was  never  greatly  dimin- 
ished, and  at  times  was  found  actually  increased,  while  the  cells  counted 
during  the  eruptive  period  showed  that  they  were  not  decreased,  but 
frequently  went  above  the  normal.  Any  alteration  in  the  erythrocytes 
as  regards  form,  the  formation  of  rouleaux,  etc.,  could  not  be  deter- 
mined, and  in  only  one  case,  during  the  height  of  the  regeneration 
of  the  leucocytes,  were  two  normoblasts  found  in  a  single  preparation. 
Xo  marked  quantitative  change  in  the  blood-plates  or  in  the  fibrin 
formation  was  made  out.  He  further  found  in  measles  a  relative,  and, 
in  a  measure,  an  absolute,  increase  of  the  large  mononuclear  cells  and 
transitional  forms. 

The  polynuclear  neutrophiles  most  frequently  show  in  the  be- 
ginning of  the  disease  an  approximately  normal  percentage,  occur- 
ring usually  on  those  days  on  which  the  mononuclear  elements  are 
present  in  greatest  abundance.  The  lymphocytes  showed  a  slight 
decrease  from  the  normal  percentage,  not  only  relatively,  but  abso- 
lutely. This  did  not  occur  equally  in  all  cases:  gradual  variations, 
depending  on  the  time  of  observation,  were  repeatedly  observed. 
Macroscopically,  at  the  time  of  the  regenerative  processes  of  the  blood 
great  variation  in  the  form  of  the  single  lymphocyte  was  noticed, 
many  forms  being  seen  which  were  plainly  in  transitional  stages  be- 
tween the  last  named  and  large  mononuclear  cells.  In  relation  to  the 
eosinophilic  cells  these  observations'  fail  to  establish  during  measles  a 
constant  relationship  to  the  other  percentages.  In  single  cases  they 
were  at  the  acme  of  the  disease  present  in  diminished  numbers  and 
during  the  time  of  the  regeneration  of  the  blood  increased  in  number, 


"BWidowitz:   "Jahrb.  f.  Kinderh.,"  B.  28,  S.  25. 
616  Franz  (Karl):  Wiener  med.  Woch.,  1899,  No.  47. 


312  THE   ACUTE    EXANTHEMATA. 

while  in  other  cases  this  relationship  was  absent.  The  most  charac- 
teristic changes  in  the  blood  in  measles,  therefore,  are  the  almost  con- 
stant relative  and  absolute  increase  of  the  large  mononnclear  cells 
and  transitional  forms  present  at  the  height  of  the  disease  and  during 
convalescence,  while  during  this  period  the  polynuclear  neutrophiles 
and  lymphocytes  are  diminished  in  number. 

In  the  majority  of  deaths  there  is  a  mixed  infection,  the  germ  most 
commonly  present  in  the  blood  being  the  staphylococcus  pyogenes 
albus.  The  streptococcus  pyogenes  is  likewise  frequently  found,  and  to 
it  is  attributed  more  serious  lesions  than  those  caused  by  the  staphy- 
lococcus. These  micro-organisms  probably  gain  access  through  the 
mucous  membrane  of  the  respiratory  tract,  and,  as  they  are  almost  in- 
variably present  in  the  wards  of  a  hospital  and  in  ill-ventilated  rooms, 
the  frequency  of  the  complications  previously  noted  is  accounted  for. 
Le  Dantec517  found  in  post-mortem  examinations  of  patients  dying 
from  measles  a  general  infection  by  streptococci.  V.  Hutinel  and  Paul 
Claisse518  have  called  attention  to  a  condition  resembling  acute  septi- 
caemia occurring  during  measles  in  very  young  children  in  which  the 
streptococcus  was  invariably  found.  Further  than  this  much  uncer- 
tainty exists. 

In  1878  Braidwood  exhibited  before  the  Pathological  Society  of 
London  what  he  claimed  to  be  the  measles  bacillus,  or  the  active  agent 
in  causing  the  disease.  In  1892  Doehle519  described  certain  bodies 
which  he  found  in  the  blood  in  eight  cases  of  measles.  In  fresh  blood 
they  were  found  both  in  the  plasma  and  red  corpuscles.  Later,  as  the 
exanthem  appeared  they  were  only  seen  in  the  latter.  These  motile 
bodies  measured  from  0.5  to  1.0  micron  in  length  and  contained  an 
opaque  nucleus  surrounded  by  a  clear  zone.  At  a  later  stage  oval 
bodies  (2  to  5  microns)  were  present,  containing  two  or  more  nuclei- 
form  bodies.  Doehle  believes  these  bodies  to  be  protozoa.  Later, 
Canon  and  Pielicke520  described  a  bacillus  which  they  had  observed 
in  fourteen  cases  of  measles  and  which  they  considered  the  specific 
organism.  It  was  found  in  the  blood,  sputum,  nasal  and  conjunctival 
secretions  during  the  whole  course  of  the  disease;  most  abundant  at 
the  height  of  the  fever  and  disappearing  as  convalescence  progressed. 
They  were  of  variable  size,  sometimes  as  long  as  one-half  the  diameter 


S1T  Le  Dantec:  Gaz.  Hebdom.  des  Sci.  Med.  de  Bordeaux,  June  19,  1892. 
618  V.  Hutinel  and  Paul  Claisse:  Revue  de  M6d.,  May  10,  1893. 
"•Doehle:  Centralb.  t.  allg.  Path.  u.  path.  Anat.,  1892,  Hi,  150-152. 
520  Canon  and  Pielicke:  Brit.  Med.  Jour.,  April  23,  1892. 


EUBEOLA.  313 

of  a  red  blood-corpuscle,  at  other  times  much  smaller,  appearing  like 
diplococci.  On  the  other  hand,  Josias321  examined  the  blood  and  se- 
cretions in  twenty-four  cases  of  measles  according  to  the  method  de- 
scribed by  Canon  and  Pielicke,  with  a  negative  result.  Among  the 
more  recent  investigations  may  be  mentioned  those  of  Czajkowski522 
who  found  bacilli  in  the  blood  varying  from  one-half  micromillimetre 
to  the  diameter  of  a  red  blood-corpuscle,  which  in  cultures  grew  into 
long  threads.  They  were  found  to  grow  best  on  bouillon  or  sterile 
serous  fluid  from  the  abdominal  cavity.  The  cultures  appeared  as  a 
whitish  sediment,  which  later  assumed  a  grayish  color.  Rabbits  were 
found  to  be  immune,  while  mice  died  from  septicaemia  in  from  three 
to  four  days  after  inoculation.  Pure  cultures  were  again  obtained  from 
the  liver  and  spleen  of  animals  thus  affected. 

In  a  study  of  665  cases  of  measles  Arsamakor523  found  rod-shaped 
bodies  with  bulb-like  extremities  present  in  the  blood  and  secretions 
from  the  inflamed  mucous  membranes.  They  were  usually  grouped, 
and  measured  from  5  to  6  microns  in  length. 

The  most  recent  investigations  which  promise  to  clear  up  the 
obscurity  existing  as  to  the  etiology  of  measles  have  been  made  by 
Lesage.524  Investigations  were  made  and  the  disease  studied  in  200 
cases  of  measles.  Eabbits  were  inoculated  with  nasal  mucus  or  blood 
from  a  large  number  of  cases.  The  results  were  positive  in  nearly  every 
case,  and  Lesage  considers  himself  justified  in  announcing  that  the 
delicate  micrococcus  so  constantly  found  has  probably  something  to  do 
with  the  etiology  of  measles.  So  far  as  it  is  possible  to  recognize  mea- 
sles on  a  hairy  animal,  he  thinks  his  inoculations  induced  the  disease. 
The  micrococcus  is  best  cultivated  on  gelose,  decolors  by  Gram's 
method,  and  takes  stains  slowly.  The  cultures  resemble  those  of  the 
pneumococcus.  It  was  not  found  in  25  cases  of  scarlet  fever,  but  con- 
stantly in  6  cases  complicated  with  measles  and  also  in  2  cases  of 
measles  complicating  diphtheria.  It  was  absent  in  45  normal  children, 
and  found  only  twice  in  53  children  who  had  had  the  disease  pre- 
viously. Much  remains  obscure,  however,  both  as  to  the  gross  pathol- 
ogy and  bacteriology  of  measles.  Future  study  of  the  blood  may 
confirm  some  of  the  observations  made,  or  reveal  something  of  as  yet 
unknown  etiological  significance.  The  pathology  of  the  various  compli- 

B21  Josias  (A.):  La  M6d.  Mod.,  June  2,  1892. 

522  Czajkowski  (Joseph):  Centralb.  f.  Bakt.  u.  Parasit.,  1895,  Nos.  17  and  18. 
B2S  Arsamakor  (G.):  Bolnitch.  Gaz.  Botk.,  1898,  40  et  41;  abstracted  in  Rev.  de  Med., 
1899,  vol.  xix,  p.  561. 

B2*  Lesage:  Bulletin  de  la  Soc.  Med.  des  Hop.  de  Paris,  March  15-22,  1900. 


314  THE    ACUTE    EXANTHEMATA. 

cations  met  with  in  measles  differs  in  no  way  from  that  found  when  not 
associated  with  this  disease. 

According  to  Franz,525  Ehrlich's  diazo-reaction  is  present  in  the 
urine,  as  a  rule,  in  nearly  all  severe  cases  of  measles,  and  on  the  aver- 
age is  first  present  on  the  third  day  of  the  disease.  In  milder  cases 
the  reaction  is  less  commonly  developed,  may  be  present  for  a  shorter 
time,  or  is  absent  altogether.  In  relation  to  the  differential  diagnosis, 
the  presence  of  this  reaction  in  a  doubtful  case  would  favor  the  diag- 
nosis of  measles.  Its  prognostic  value  in  this  disease  is  slight. 

In  regard  to  the  involvement  of  the  lymphatic  glands  in  measles 
there  is  much  variability.  As  a  rule,  inflammation  is  less  marked  than 
in  scarlet  fever  or  German  measles.  When  extensive  destruction  of 
tissue  takes  place,  as  is  sometimes  observed  in  the  naso-pharyngeal  cav- 
ities, enlargement  and  infiltration  of  the  adjacent  lymphatic  glands 
ensue,  which  in  strumous  subjects  frequently  eventuates  in  suppura- 
tion and  destruction  of  the  gland-structure.  The  lungs  are  implicated 
in  a  large  majority  of  cases  which  terminate  fatally.  The  changes 
found  in  the  lungs  do  not,  in  the  main,  differ  from  those  observed  when 
unaccompanied  by  measles.  Corneil  and  Babes526  maintain,  however, 
that  there  is  a  special  form  of  inflammation  of  the  kings  which  they 
believe  to  be  peculiar  to  measles  and  due  to  the  direct,  action  of  the 
specific  poison.  They  regard  it  as  the  sole  cause  of  death  in  the  so- 
called  suffocative  form.  It  begins  as  an  interstitial  pneumonia,  at  first 
involving  the  lymphatic  system,  the  interlobular  and  interalveolar  tis- 
sue, which  later  gives  rise  to  a  fibrinous  effusion  into  the  alveoli.  The 
anatomical  changes  found  in  the  central  nervous  system  are  at  first 
mainly  vascular,  and  are  likewise  supposed  to  be  due  to  the  direct 
toxic  effect  of  the  measles  virus.  Analogy  is  drawn  between  similar 
changes  observed  in  diphtheria,  which  in  like  manner  are  supposed  to 
be  due  to  the  specific  effect  of  the  toxic  agent. 

ETIOLOGY. 

Measles  is  eminently  a  contagious  and,  to  a  less  extent,  an  in- 
fectious disease.  It  is  usually  communicated  direct  from  person  to 
person,  and  in  this  way  it  is  the  most  contagious  of  the  exanthemata. 
Its  communicability,  however,  has  greater  limitations  than  is  observed 
in  both  small-pox  and  scarlet  fever,  because  the  contagium  does  not 
readily  adhere  to  clothing  and  soon  loses  its  infective  property.  Fur- 

S26  Franz  (Karl):  Wiener  med.  Woch.,  1899,  No.  46. 

628  Corneil  and  Babes,  quoted  by  Williams  (loc.  Cit.,  p.  125). 


RUBEOLA.  315 

thermore  it  is  known  that  the  infectious  material  does  not  readily 
adhere  to  the  walls  or  other  objects  in  the  sick-chamber;  therefore 
there  is  less  danger  of  infection  from  fomites;  consequently  inter- 
mediate contagion  is  comparatively  rare.  It  is  further  known  that 
exposure  to  the  air  and  sunlight  for  a  short  time  renders  the  contagium 
innocuous.  In  studying  the  influences  which  bear  on  the  spread  of 
measles,  Richard.527  from  an  experience  of  three  epidemics,  concludes 
that:  the  contagium  cannot  be  carried  by  fomites  or  a  protected  person, 
neither  does  it  spread  through  the  atmosphere,  and  that  strict  quaran- 
tine will  prevent  it. 

Bard528  draws  the  following  conclusions  bearing  on  the  etiology 
of  measles:  The  contagium  of  morbilli  does  not  remain  viable  in  a 
locality  from  which  those  who  have  suffered  from  the  disease  have  gone 
away.  Hence,  disinfection  of  the  bed  and  furniture  is  unnecessary. 
Contagion  is  always  direct,  from  person  to  person.  While  it  is  highly 
probable  that  measles  is  due  to  a  microparasite,  yet  at  the  present  time 
no  microbe  has  been  identified  and  proved,  beyond  reasonable  doubt, 
to  be  the  specific  agent.  Contagion  is  possible  even  three  or  four 
days  before  the  eruption  on  the  skin  is  evident,  and  continues  until  des- 
quamation  has  ceased.  In  5  cases  collected  by  Ransome529  measles  was 
found  to  be  infectious  before  the  appearance  of  the  rash;  in  2  cases 
at  least  2  days  before  that  event.  In  1  case  3  days  before  the  rash 
appeared  it  failed  to  give  the  disease  to  7  susceptible  children. 
Croskey530  observed  a  case  in  which  the  disease  was  apparently  com- 
municated 4  days  before  the  rash  appeared.  Yacher331  places  the 
duration  of  infection  at  31  days  after  invasion. 

The  virus  is  present  in  the  blood  even  during  the  prodromal  stage, 
as  has  been  demonstrated  by  inoculation.  The  first  successful  inocula- 
tions of  which  we  have  any  record  were  made  by  Home,  of  Edinburgh, 
in  1758.  These  observations  were  confirmed  by  Speranza  in  1822  and 
in  1854  by  Bufalini.  The  catarrhal  secretions  from  the  various  mu- 
cosae  have  been  demonstrated  to  contain  the  infective  material  by  both 
Mayr532  and  Berndt.533  Further,  the  latter  observer  has  demonstrated 
that  the  disease  may  be  communicated  by  desquamating  epithelium. 


627  Richard  (V.  M.):  Therapeutic  Gazette,  July  16,  1888. 

528  Bard:  Revue  d'Hygiene  et  de  Police  Sanitaire,  May  20,  1891. 

529  Ransome:  Brit.  Med.  Jour.,  Jan.  29,  1887. 

530  Croskey,  cited  by  Ransome  (loc.  cit.). 
»31  Vacher,  cited  by  Ransome. 

532  Mayr  (Thomas):   Article,  "Measles"  (op.  cit.,  p.  40). 
"*  Berndt,  cited  by  Thomas  (loc.  cit.,  p.  40). 


316  THE   ACUTE    EXANTHEMATA. 

With  the  subsidence  of  the  exanthem,  however,  the  disease  becomes  less 
contagious,  and  Mayr  was  unable  to  communicate  it  at  this  time  by 
rubbing  desquamated  scales  fresh  from  a  case  of  measles  into  the  de- 
nuded skin  of  a  susceptible  subject.  It  is  unwise,  however,  as  abundant 
clinical  experience  testifies,  to  disregard  the  element  of  contagion  until 
all  desquamation  has  ceased,  and  clothing,  utensils,  and  apartments 
have  either  been  disinfected  or  exposed  to  fresh  air  and  sunlight  for 
at  least  a  day. 

Susceptibility  to  the  contagium  of  measles  is  almost  universal, 
and  few  escape  after  direct  exposure  unless  protected  by  a  previous 
attack.  People  differ,  however,  as  to  susceptibility,  some  contracting 
the  disease  by  a  very  short  exposure,  while  others  require  more  in- 
timate or  protracted  contact.  Naturally  where  apartments  are  ill 
ventilated,  and  many  patients  are  confined  in  one  room,  the  danger  of 
communicating  the  disease  is  greater  than  where  proper  hygienic 
measures  are  carried  out.  Thus,  in  schools,  kindergartens,  and  asy- 
lums the  greatest  danger  of  infection  exists.  One  attack,  however, 
usually  confers  immunity  for  life.  Second  attacks  of  measles  are  ex- 
ceedingly rare,  and  in  this  respect  it  does  not  differ  "from  that  observed 
in  variola,  scarlet  fever,  and  varicella.  Third  attacks,  as  in  the  other 
exanthemata,  have  been  recorded,  though  this  must  be  looked  upon  as 
a  great  rarity.  Such  cases  have  been  reported  by  Van  Dieren  and  Bier- 
baum  (cited  by  Thomas).  Most  instances  of  apparent  relapse,  or  so- 
called  second  attacks,  are,  in  reality,  cases  of  roseola,  or  German  mea- 
sles, as  the  latter  may  readily  be  mistaken  for  measles,  and  in  the  au- 
thor's experience  many  cases  supposed  to  be  second  attacks  of  measles 
were  found  to  belong  to  the  erythematous  group.  This  is  in  conformity 
with  the  opinion  expressed  by  nearly  all  who  have  had  a  wide  experi- 
ence with  the  disease.  Thomas  (loc.  cit.)  cites  Rosenstein  (1789),  who 
devoted  the  closest  attention  to  eruptive  diseases  during  a  period  of 
forty-four  years  without  encountering  a  second  attack  of  measles  in 
the  same  person.  Willan  (loc.  cit.)  did  not  meet  with  a  single  instance 
in  which  -measles  occurred  a  second  time  accompanied  by  fever. 
Panum,534  from  an  immense  number  of  observations,  has  not  reported 
a  single  case  in  which  measles  occurred  the  second  time.  Thomas,  in 
his  extensive  experience,  has  not  met  with  a  single  case.  There  are 
good  grounds  for  believing  that  error  has  occurred  in  many  cases  ap- 
parently contradicting  such  an  array  of  experience.  Second  attacks 


584  Panum:  Virchow's  Archiv,  i,  1848. 


RUBEOLA.  317 

of  measles  may,  however,  occur,  as  has  been  stated.  Most  of  the 
authentic  cases  on  record  have  occurred  either  a  few  weeks  after  the 
original  attack  or  after  several  years. 

Xo  age  is  wholly  exempt,  although  measles  is  less  commonly  seen 
in  infants  under  one  year  of  age  and  in  old  people.  According  to  Mayr 
(loc.  cit.},  of  10  nurslings  exposed  to  measles,  1  only  contracted  the 
disease.  In  an  epidemic  in  the  Foundling  Hospital  at  Bordeaux 
Barbillier535  reports,  of  33  children  between  one  and  seven  years  of 
age,  24  were  attacked,  while  of  40  children  under  one  year  of  age  only 
7  were  attacked.  On  the  other  hand,  when  measles  is  introduced  into 
a  previously  non-infected  community,  all  ages  and  both  sexes  are  at- 
tacked. Thus,  in  the  Canary  Islands  measles  had  been  wholly  absent 
for  a  period  of  at  least  sixty-five  years  previous  to  1846,  when  an  in- 
fected person  landed,  infecting  6000  of  the  7782  inhabitants.  Why 
measles  is  seldom  seen  in  adult  life  may  be  readily  understood  when 
we  consider  how  few  children  escape  exposure.  In  most  countries 
measles  is  endemic,  although  epidemics  occur  at  frequent  intervals. 
Few,  therefore,  escape  infection  in  early  life.  It  is  most  commonly 
met  with  between  two  and  ten  years  of  age,  although  the  contagium 
may  be  transmitted  to  the  child  in  utero.536  Thomas  (loc.  cit.,  p.  50) 
has  collected  six  instances  in  which  the  exanthem  of  measles  was  pres- 
ent at  birth.  After  citing  several  cases  of  measles  appearing  a  few 
days  after  birth  in  children  whose  mothers  had  contracted  the  disease 
just  previous  to  delivery,  von  Jiirgensen  (loc.  cit.,  p.  44)  draws  the  con- 
clusion that  the  virus  is  conveyed  through  the  placental  circulation. 
On  the  other  hand,  Thomas  cites  an  instance  of  measles  occurring  in 
a  mother  at  the  fifth  month  of  gestation  in  which  the  foetus  was  not 
affected,  as  it  had  the  disease  at  the  age  of  nine  years  at  the  same  time 
with  its  brothers  and  sisters.  Finally,  measles  has  been  reported  at  the 
age  of  80  (Drake)  and  at  83  (Michaelson).  The  disease  is  more  prev- 
alent during  the  cool  than  during  the  warm  months,  and  in  the  United 
States  most  cases  occur  during  the  autumn  and  spring  months.  More 
cases  are  reported  during  March,  April,  and  May  than  during  the  corre- 
sponding autumnal  period.  Whitelegge,537  after  carefully  compiling 
statistics  in  Great  Britain,  believes  the  interval  between  epidemics  is 


635  Barbillier  (L.),  cited  by  Thomas,  p.  49. 

534  Ballantyne  (J.  A.):    "Congenital  Measles,  with  Note  of  a  Case."     Archives  of 
Ped.,  April,  1893. 

537  Whitelegge:  Brit.  Med.  Jour.,  1893,  vol.  i,  p.  451. 


318  THE    ACUTE    EXANTHEMATA. 

about  two  years.  Again,  about  once  in  ten  years  an  epidemic  of  un- 
usual severity  occurs  accompanied  by  a  high  rate  of  mortality.  In 
some  decennial  epidemics  double  or  even  treble  the  ordinary  mortality 
may  be  observed.  In  Great  Britain  and  on  the  continent  of  Europe  two 
yearly  maxima  are  reached  at  the  beginning  of  winter  and  at  the  be- 
ginning of  summer. 

All  races  seem  likewise  susceptible  to  the  disease.  It  is  generally 
observed  that,  when  measles  is  introduced  into  a  country  or  community 
previously  free  from  the  disease,  it  appears  with  unusual  severity. 
Thus,  among  the  Indians  of  this  continent  it  was  greatly  dreaded. 

According  to  Bard  (loc.  cit.),  broncho-pneumonia  is  usually  a  sec- 
ondary or  additional  infection,  but  it  may  co-exist  with  the  morbilli,  in 
which  case  it  manifests  a  mixed  infection. 

It  is  claimed  by  some  that  measles  may  attack  certain  animals, 
and  the  experiments  of  Behla,538  in  which  he  inoculated  a  young  pig 
with  secretions  from  the  mouth  and  nose  of  a  case  of  measles,  seems 
to  prove  this  assertion.  In  this  case  there  appeared  four  days  later  a 
discharge  from  the  nose  and  the  catarrhal  symptoms  of  the  eyes  such 
as  observed  in  the  prodromal  stage  of  measles  in  the  human  subject. 
On  the  fifth  day  the  animal  was  observed  to  be  ill,  and  with  loss  of 
desire  for  food  and  marked  shivering;  the  temperature  soon  rose  to 
103°  F.  (39.4°  C.).  On  the  eight  day  on  the  muzzle,  cheeks,  and  ears, 
together  with  other  parts,  partially  devoid  of  hair  about  the  head  and 
neck,  there  were  found  reddish  spots.  This  extended,  in  the  course 
of  twenty-four  hours,  over  the  whole  body.  In  appearance  this  re- 
sembled the  rash  observed  in  human  measles,  and  was  followed  by 
desquamation.  Fourteen  days  later  an  adult  pig  which  had  come  in 
contact  with  the  one  inoculated  came  down  with  the  disease,  which 
lasted  about  four  days,  terminating  in  a  slight  desquamation  as  in  the 
one  preceding.  Seven  days  later  another  pig  belonging  to  the  same 
sty  had  a  similar  attack.  It  was  regarded  as  swine  fever,  although  an 
examination  of  the  blood  and  mucous  secretions  did  not  reveal  the 
bacillus  found  in  this  disease.  Josias539  repeated  Behla's  experiments 
with  a  negative  result.  Similar  eruptions  have  been  seen  in  sheep 
and  dogs,  and  recently  Chavigny540  has  observed  measles  in  an  ape. 
Until  we  ascertain  the  specific  cause  of  measles  it  is  difficult  to  draw 
definite  conclusions  as  to  the  character  of  the  eruptions  here  cited. 


m  Behla:  Centralb.  f.  Bakt.  und  Parasit.,  xx,  16  und  17. 

"•  Josias:  La  M6d.  Mod.,  No.  20,  1898. 

540  Chavigny:  Bull.  M£d.,  Paris,  1898,  12,  p.  334. 


RUBEOLA.  311) 

DIAGNOSIS. 

The  epidemic  character  of  measles  renders  a  valuable  aid  in  diag- 
nosis and  in  determining  the  nature  of  a  suspected  case;  at  the  same 
time  one  must  not  lose  sight  of  the  fact  that  sporadic  cases  occur  from 
time  to  time,  and,  when  isolated  or  when  susceptible  people  are  not 
exposed,  its  contagious  or  epidemic  nature  may  not  be  disclosed.  How- 
ever, the  diagnosis  of  measles  is  usually  not  difficult  when  one  bears 
in  mind  and  understands  the  relative  importance  of  the  various  symp- 
toms that  have  been  already  detailed.  Furthermore,  it  is  especially 
important,  on  account  of  the  variations  which  are  known  to  take  place, 
to  rely  more  on  the  general  ensemble  as  revealed  by  a  careful  examina- 
tion than  on  any  one  symptom  or  even  set  of  symptoms  alone.  Thus 
the  prodromal  period  often  presents  departures  from  the  normal,  and 
later  the  rash  in  measles  may  be  closely  simulated  by  other  affections 
totally  dissimilar  in  character.  The  early  recognition  of  measles  is  of 
the  highest  importance,  because  the  disease  is  contagious  as  soon  as 
the  prodromal  symptoms  appear,  and  it  has  been  conclusively  shown 
that  in  the  majority  of  cases  infection  occurs  during  the  prodromal 
stage. 

Influenza. — At  this  time  the  affection  most  commonly  mistaken 
for  measles  is  influenza  or  simple  coryza.  The  mother  recognizes  in 
the  symptoms  of  measles  during  the  first  twenty-four  hours  the  usual 
phenomena  of  a  "common  cold,"  while,  on  the  other  hand,  the  epi- 
demic feature  of  influenza  is  liable  to  confuse  the  medical  attendant, 
and,  should  erythematous  lesions  of  almost  any  form  supervene,  an 
error  in  diagnosis  is  frequently  made.  In  all  cases  the  wisest  course 
is  to  isolate  the  patient  so  far  as  practicable  until  the  further  develop- 
ment of  the  disease  enables  the  physician  to  form  an  intelligent  opinion 
as  to  its  nature.  The  inexperienced  too  frequently  err  in  attempting 
to  make  a  diagnosis  without  sivfficient  deliberation  and  without  wait- 
ing for  the  establishment  of  a  sufficient  number  of  distinctive  symp- 
toms. Under  such  circumstances  it  is  the  duty  of  the  physician,  and 
one  which  will  redound  to  his  own  credit,  to  explain  to  the  family  that 
the  disease  has  not  sufficiently  developed  to  warrant  an  opinion  as  to 
its  name,  but  that  precautions  against  exposing  others  should  be  taken 
until  its  true  nature  is  revealed.  During  the  first  day  the  main  con- 
siderations are  as  to  the  prevalence  of  an  epidemic  and  whether  or  not 
the  patient  has  been  exposed  to  any  contagious  disease.  In  influenza 
the  rise  of  temperature  is  less  marked  than  in  measles,  and  there  is  less 
photophobia.  Vomiting  is  rare  in  influenza  and  common  during  the 


320  THE    ACUTE    EXANTHEMATA. 

prodromal  stage  of  measles.  On  the  second  day  and  sometimes  even 
on  the  first  the  buccal  mucous  membrane  usually  affords  positive  diag- 
nostic signs.  In  influenza  the  mucous  membrane  of  the  mouth  is  ordi- 
narily normal,  the  pharynx  and  tonsils  are  usually  reddened  and  the 
latter  often  swollen,  while  in  measles  the  whitish-blue  color  of  the 
inner  surface  of  the  cheeks  and  lips,  together  with  the  dark-reddish 
spots,  speckled  with  whitish,  vesicle-like  bodies, — the  enanthem  of 
measles, — may  in  most  cases  be  recognized.  On  the  third  day  the  enan- 
them continues  to  develop,  while  the  fever  and  other  symptoms  may 
subside.  There  should  be  no  delay  in  establishing  strict  quarantine 
with  the  appearance  of  these  pathogenic  symptoms,  although  unfortu- 
nately the  physician  is  seldom  called  until  exposure  has  already  taken 
place. 

Rubella,  or  German  Measles. — With  the  appearance  of  the  rash  on 
the  skin  and  during  the  course  of  the  exanthem,  rubella  is  undoubtedly 
more  frequently  mistaken  for  measles  than  any  other  disease.  The 
differential  diagnosis  between  these  affections  will  be  fully  considered 
under  "Rubella."  > '  { 

Scarlet  Feuer. — The  early  differentiation  between  measles  and 
scarlet  fever  is  of  less  moment  than  between  measles  and  certain  other 
affections,  especially  those  of  a  non-infectious  nature.  Moreover, 
measles  is  liable  to  be  mistaken  for  scarlatina  only  in  special  cases.  At 
the  outset  there  may  be  anorexia,  vomiting,  drowsiness,  or  irritability 
and  a  rapid  rise  of  temperature  in  both  diseases,  but  in  scarlet  fever 
the  congestive  disturbance  of  the  mucous  membranes  is  mainly  con- 
fined to  the  pharynx,  tonsils,  and  larynx,  with  less  photophobia  or 
dread  of  light  so  common  in  measles.  In  scarlet  fever  there  is  tender- 
ness about  the  neck,  with  pain  on  palpating  the  submaxillary  glands, 
which  are  frequently  swollen,  while  in  measles  these  are  replaced  by  a 
more  general  catarrhal  condition  of  the  upper  air-passages,  giving  rise 
to  coryza  and  a  dry,  barking  cough.  The  tongue  in  scarlet  fever  soon 
becomes  reddened  at  the  tip  and  margins  with  swollen  papillae  project- 
ing?— the  "strawberry  tongue," — while  in  measles  it  either  remains 
covered  with  a  whitish  fur  or  becomes  red  with  a  few  enlarged  papilla? 
which  appear  at  a  later  stage  of  the  disease.  The  buccal  mucous  mem- 
brane in  scarlet  fever  is  of  a  bright-reddish  tint,  with  the  uvula  greatly 
injected,  while  in  measles  the  pale-bluish  tint,  together  with  the  char- 
acteristic enanthem,  are  usually  sufficiently  distinctive  to  differentiate 
between  them. 

The  duration  of  the  prodromal  stage  should  likewise  be  taken 


PLATE  XXXIX. 


XXXIX 

RUBEOLA — showing  grouping  of  the  lesions. 


PLATE  XL. 


XL 

RUBEOLA — the  eruption  becoming  confluent  on  the  chest,  resembling 
somewhat  the  eruption  of  scarlet  fever. 


RUBEOLA.  321 

into  account:  in  scarlet  fever  twenty-four  hours  or  less,  seldom  longer, 
while  in  measles  the  rash  does  not  appear  until  the  fourth  day.  Usually 
the  bright-red,  punctate  eruption  of  scarlet  fever  is  quite  unlike  the 
cyanotic  features  and  dark-red  maculae  of  measles,  but  in  individual 
cases  it  must  be  admitted  some  difficulty  may  be  experienced  in  dif- 
ferentiating them.  This  is  less  so,  however,  than  between  German 
measles  and  scarlet  fever,  which  frequently  closely  simulate  each  other. 
In  scarlet  fever,  while  the  exanthem  may  consist  of  distinct  lesions 
with  normal  integument  intervening,  yet  the  spots  are  smaller  and 
tend  to  the  punctate  form.  On  the  other  hand,  the  lesions  may 
coalesce  in  measles,  forming  wide  areas  of  the  eruption;  still,  at  the 
margin  and  on  other  parts  of  the  body  there  will  be  found  those  which 
adhere  to  the  measles  type.  (See  Plate  XXXIX.) 

Erythema,  Roseola,  Nettle-rash,  and  Prickly  Heat. — In  young  chil- 
dren these  are  often  accompanied  by  more  or  less  digestive  disturb- 
ances, yet  the  catarrhal  symptoms  of  measles  are  absent  and  there  is 
little  or  no  constitutional  disturbance.  The  temperature  remains  nor- 
mal, or  at  most  is  but  slightly  elevated,  and  then  only  for  a  short  time. 
The  rash  may  resemble  that  of  measles  in  some  of  these  cutaneous 
disorders,  but  it  never  appears  in  the  order  observed  in  measles.  Ery- 
thema most  frequently  appears  on  the  back  of  the  hands,  forearms,  and 
feet,  while  simple  roseola  is  often  limited  to  the  face,  or  extends  only 
to  the  neck  and  chest,  rarely  over  the  whole  body.  Furthermore  they 
are  of  short  duration  and  the  latter  quite  evanescent.  The  lesions  in 
erythema  are  usually  larger,  sometimes  forming  more  or  less  extensive 
plaques,  while  roseola  simulates  more  closely  the  deep  blush  of  scarlet 
fever.  The  entire  absence  of  constitutional  symptoms  and  coryza  are 
sufficient  to  distinguish  the  rashes  due  to  excessive  perspiration  and 
the  irritation  produced  by  flannel  or  other  rough  clothing. 

Drug  Eruptions. — Certain  drugs  are  known  to  produce  rashes  of 
various  kinds,  and  when  given  for  some  slight  febrile  disorder,  as  in 
influenza  and  "colds,"  there  sometimes  appears  a  condition  which  may 
readily  be  mistaken  for  measles.  This  illustrates  the  importance  of  ob- 
taining a  correct  history  of  the  case,  and  especially  when  called  after 
the  disease  is  well  advanced,  before  making  a  diagnosis.  The  drug  erup- 
tions most  liable  to  be  mistaken  for  measles  are  those  of  quinine  and 
antipyrin,  because  these  drugs  are  most  commonly  employed  in  disturb- 
ances simulating  the  prodromal  stage  of  measles.  Thus,  in  an  analysis 
of  sixty  cases  of  quinine  eruption,  Morrow541  found  thirty-eight  were 


641  Morrow  (Prince  A.):   "Drug  Eruptions"  (New  York,  1887). 

21 


322  THE    ACUTE    EXANTHEMATA. 

of  the  erythematous  form.  In  most  cases  it  appears  as  an  efflorescence 
of  a  bright,  vivid  hue,  which  disappears  on  pressure  and  closely  re- 
sembles the  rash  of  scarlatina.  Less  frequently  the  color  is  of  a  darker 
hue,  and  it  appears  in  the  form  of  distinct  red  spots,  which  may  become 
confluent  or  patchy,  when  it  closely  resembles  the  exanthem  of  measles. 
Usually  it  appears  first  on  the  face  and  neck,  after  which  it  soon  be- 
comes diffused  over  the  whole  surface  of  the  body.  In  exceptional 
cases  or  when  the  drug  has  been  discontinued,  it  remains  limited  to 
face,  upper  part  of  the  chest,  or  arms.  Upon  discontinuing  the  drug 
the  eruption  quickly  disappears,  and,  as  in  both  scarlatina  and  measles, 
is  followed  by  a  branny,  or  lamellar,  desquamation.  The  mere  fact 
that  the  administration  of  quinine  is  sometimes  followed  by  a  rash 
should  guard  against  its  being  mistaken  for  measles.  If  any  doubt 
exist,  a  prompt  discontinuance  of  the  drug  would  enable  one  to  ac- 
cept or  exclude  the  administration  of  quinine  as  an  etiological  factor. 
Ernst542  was  the  first  to  recognize  the  close  resemblance  between  the 
rash  of  antipyrin,  which  he  observed  in  five  cases,  and  that  of  mor- 
billi.  In  the  cases  thus  reported  the  rash  appeared  on  the  trunk  and 
extremities,  as  well  as  on  the  palmar  and  plantar  surfaces.  Antip}rrin  as 
usually  observed  gives  rise  to  an  erythematous  eruption  having  its  seat 
of  predilection  on  the  chest,  abdomen,  and  back;  rarely  on  the  face 
and  neck;  and  only  occasionally  on  the  extremities.  Xext  to  quinine, 
it  is  more  liable  to  be  mistaken  for  the  rash  of  measles  than  any  other 
drug  efflorescence:  first,  because  it  usually  accompanies  or  follows 
an  elevated  temperature,  for  which  the  drug  has  been  given;  second, 
because  the  individual  lesions  bear  a  close  resemblance  to  those  of 
measles.  It  may  appear  after  the  administration  of  a  single  dose,  and 
consists  of  small,  irregularly  circular,  slightly  elevated  reddish  blotches, 
which  may  either  be  discrete  or  confluent,  forming  large  patches  of 
rarious  shapes  and  sizes.  The  absence  of  the  efflorescence  on  the  face 
and  neck,  together  with  the  freedom  from  the  catarrhal  symptoms  of 
morbilli,  will  usually  enable  the  physician  to  differentiate  between 
them.  Antipyrin  never  gives  rise  to  the  peculiar  buccal  enanthem  of 
morbilli. 

The  internal  administration  of  chloral  is  sometimes,  though 
rarely,  followed  by  an  efflorescence  of  the  skin.  It  appears  in  the  form 
of  a  diffused,  bright  redness  of  uniform  character,  which  first  shows 
on  the  face  and  successively  becomes  distributed  over  the  neck,  chest, 
and  extremities,  with  a  special  predilection  to  affect  the  integumental 

542  Ernst:   Centralb.  f.  klin.  Med.,  1884,  No.  33. 


RUBEOLA.  323 

covering  of  the  joints,  notably  the  knees,  wrists,  elbows,  and  ankles. 
On  the  face  it  most  frequently  becomes  manifest  as  a  diffused  redness, 
while  on  other  parts  of  the  body  it  consists  of  dusky-red  spots  or  patches 
of  various  sizes,  irregular  in  outline,  which  give  to  the  skin  a  mottled 
appearance.  As  pointed  out  by  Morrow  (loc.  cit.},  the  efflorescence  be- 
comes more  pronounced  after  the  ingestion  of  food  or  alcohol,  and 
sometimes  recurs  after  each  meal  for  some  time  after  the  discontinu- 
ance of  the  drug.  The  absence  of  all  catarrhal  or  suffusive  disturb- 
ances of  the  conjunctivas  and  upper  air-passages  would  readily  enable 
one  to  exclude  inorbilli. 

When  "balsams"  were  administered  per  oram  in  the  treatment  of 
urethritis,  it  was  not  unusual  to  see  a  measles-like  eruption  following 
the  use  of  ciibebs  and  copaiba.  As  these  drugs  are  seldom  administered 
to  children,  and  as  the  peculiar  balsamic  odor  attending  their  use  is 
readily  detected,  there  is  little  likelihood  of  their  being  mistaken  for 
the  exanthem  of  measles.  However,  as  this  has  occurred,  it  may  be 
well  to  mention  some  of  the  principal  points  of  distinction:  The  rash 
following  the  use  of  both  copaiba  and  cubebs  varies  somewhat  in  char- 
acter, but  generally  appears  in  the  form  of  reddish  spots  of  a  bright 
color,  varying  from  a  split  pea  to  a  dime  in  size,  separated  by  normal 
skin,  although  at  times  coalescing  and  forming  irregular  patches  of  a 
considerable  size.  The  lesions  disappear  on  pressure,  as  in  measles; 
they  are  not,  however,  elevated  above  the  level  of  the  skin  as  in  the 
latter  disease.  Finally,  the  strong  tendency  to  appear  around  the 
articulations  of  the  extremities  is  especially  noteworthy,  and  serves  to 
distinguish  the  drug  eruption  from  the  exanthem  of  measles.  Some- 
times, however,  the  efflorescence  appears  on  the  face  and  neck,  when 
they  bear  a  closer  similitude,  and  it  is  in  these  cases  that  mistakes  are 
usually  made.  No  changes  are  observed  in  the  mucous  membranes. 

Various  Other  Less  Frequent  Sources  of  Error  in  the  Diagnosis 
of  Measles. — Numerous  other  cutaneous  disturbances  might  be  men- 
tioned which  in  themselves  bear  a  more  or  less  striking  resemblance 
to  the  rash  met  with  in  measles.  It  is  only  in  very  exceptional  in- 
stances, however,  that  any  uncertainty  need  exist  in  their  differential 
diagnosis.  Thus,  the  bites  of  insects,  especially  bed-lugs,  fleas,  and 
mosquitoes,  sometimes  produce,  in  children  possessing  delicate  or  sus- 
ceptible skins,  an  eruption  which  at  first  sight  might  arouse  a  suspicion 
of  measles.  Their  sudden  appearance,  however,  unaccompanied  by 
any  general  disturbance,  should  serve  to  exclude  an  infectious  con- 
stitutional disease  like  measles. 


324  THE   ACUTE    EXANTHEMATA. 

Again,  the  symptomatic  roseola  or  erythema  which  sometimes 
precedes  typhus  fever,  cholera,  and  other  affections  may  occasion  some 
uncertainty,  although  this  is  possible  for  a  short  time  only,  as  the 
probability  of  measles  will  soon  be  eliminated  by  the  subsequent  course 
of  the  disease. 

The  prodromal  roseola  of  small-pox  and  its  differential  diagnosis 
from  measles  has  already  been  treated  of  under  the  former  disease. 

The  rashes  following  the  injection  of  antitoxin  serum  in  diph- 
theria and  antistreptococcic  serum  may  simulate  the  rash  of  measles; 
but,  again,  the  constitutional  symptoms  are  usually  so  dissimilar  that 
the  mere  knowledge  that  such  efflorescences  sometimes  follow  the  use 
of  these  substances  should  be  sufficient  to  insure  safety  from  a  diag- 
nostic stand-point. 

In  syphilis  the  early  eruption,  which  is  of  a  mottled  or  macular 
character,  may  present  a  blotchy  or  "measly"  appearance.  Further, 
the  mucous  surfaces  in  syphilis  participate  in  the  general  efflorescence. 
Syphilis  usually  occurs  in  young  adults,  while  measles  is,  for  the  most 
part,  a  disease  of  childhood.  Furthermore,  during  the  early  stage  of 
syphilis  the  initial  lesion  is  usually  still  present,  or  an  indurated  scar 
indicating  its  former  site  offers  a  valuable  diagnostic  guide.  It  is  only 
when  syphilis  is  acquired  in  childhood  that  the  two  eruptions  are  liable 
to  be  confounded.  In  this  case  the  general  symptoms  are  sufficiently 
distinctive  to  readily  distinguish  between  them  when  ordinary  care  is 
taken.  The  absence  of  fever  and  coryza  in  syphilis,  together  with  its 
slow  course,  offers  sufficient  contrast  to  the  acute  catarrh  and  febrile 
prodrome  of  measles.  Again,  aphthous  stomatitis,  frequently  associated 
with  anorexia,  irritability,  and  fever,  must  not  be  mistaken  for  the 
enanthem  of  measles.  It  may  be  observed  that  the  aphthous  spots  are 
much  larger,  are  of  a  more  yellow  or  wash-leather  color,  and  soon 
ulcerations  appear. 

In  the  dark-skinned  and  colored  races  the  characteristic  cutaneous 
exanthem  is  modified  and  may  afford  little  assistance  in  diagnosis.  In 
the  Malay  and  North-American  Indian  the  eruption  presents  a  marbled 
appearance  or  occurs  in  irregularly  shaped  coppery  blotches.  This  is 
followed  by  desquamation,  as  in  the  Caucasian.  Negroes  present 
slightly  mottled,  elevated,  or  lichen-like  plaques,  which  are  best  recog- 
nized by  the  touch,  and  later  by  a  whitish  desquamative  condition  of  the 
skin.  Of  the  greatest  value  in  this  class  of  cases  are  the  changes  ob- 
served in  measles  in  the  various  mucous  membranes.  These,  with  the 
rise  of  temperature  and  general  symptoms  complained  of,  must  be 


KUBEOLA.  325 

relied  upon  in  arriving  at  a  conclusion  as  to  the  nature  of  the  dis- 
ease. 

Measles  without  exanthem  presents  even  greater  difficulties,  and 
probably  would  not  be  recognized  in  the  absence  of  an  epidemic  or 
other  well  marked  cases  in  the  immediate  vicinity.  The  prodromal 
symptoms  must  be  taken  into  account  and  the  condition  of  the  mucous 
membranes,  which,  with  the  characteristic  lesions  in  the  buccal  cavity, 
will,  in  the  majority  of  cases,  enable  the  physician  to  recognize  the  dis- 
ease even  when  the  exanthem  is  absent.  As  yet  the  claims  of  Bolognini, 
previously  mentioned,  relative  to  the  value  of  peritoneal  crepitation  as 
a  diagnostic  aid,  have  not  been  sufficiently  verified.  Fortunately  in 
many  cases  there  is  a  rudimentary  or  abortive  rash  about  the  face  and 
neck,  which,  with  the  usual  symptoms,  will  enable  a  diagnosis  to  be 
made  with  certainty. 

PROGNOSIS. 

Measles  pursuing  a  normal  course  and  when  uncomplicated  with 
other  diseases  seldom  ends  in  death.  The  complications  of  measles, 
on  the  other  hand,  are  exceedingly  grave,  both  as  to  life  and  to  the 
more  or  less  permanent  impairment  of  the  general  health  or  of  special 
organs  of  sense.  The  conditions  which  tend  to  the  development  of  cer- 
tain diseases  during  the  course  of  measles,  and  the  liability  to  various 
complications  and  anomalies  which  militate  against  a  favorable  prog- 
nosis, are:  the  age  of  the  patient;  various  influences  which  impair  the 
general  health,  such  as  unhygienic  surroundings  and  overcrowding;  the 
predisposition  to,  or  presence  of,  tuberculosis  or  the  strumous  state; 
and  the  severity  of  the  prevailing  epidemic.  Fortunately  infantile  sus- 
ceptibility to  measles  is  far  less  than  obtains  later  in  childhood  and 
adolescence.  Even  when  it  does  occur  during  the  first  six  months  of 
life  it  is  often  mild  and  clinically  presents  a  strong  resemblance  to 
rubella.  After  this  period  and  during  the  first  dentition  the  suscepti- 
bility to  the  affection  increases,  while  the  fatality  becomes  correspond- 
ingly high.  The  greatest  fatality  is  met  with  under  two  years.  This 
is  in  accord  with  the  observation  of  clinicians  both  in  this  country  and 
in  Europe.  After  studying  the  disease  in  a  large  number  of  cases  and 
during  many  epidemics,  Holt  (loc.  cit.,  p.  923)  estimates  the  fatality 
of  measles  in  children  of  all  ages  to  be  from  4  to  6  per  cent.,  while  un- 
der two  years  of  age  it  is  frequently  20  per  cent,  or  even  more.  Ac- 
cording to  Williams  (loc.  cit.},  there  occurred  in  England  and  Wales 
367,602  deaths  attributed  to  measles  during  the  forty  years  from  1848 
to  1887.  Of  this  number  335,874  were  in  children  less  than  five  years 


326  THE   ACUTE    EXANTHEMATA. 

of  age,  leaving  only  31,728  to  be  distributed  among  those  of  five  years 
of  age  and  older.  Under  five  years  of  age  the  distribution  is  shown 
in  the  following  table,  which  is  taken  from  his  valuable  article: — 

Under  1  year,  male 3.01  deaths  per  1000  living  at  that  age. 

"  1000  "  "  " 

"  1000  "  "  " 

"  1000  "  "  " 

"  1000  "  "  "   " 

"  1000  "  "  " 

"  1000  "  "  " 

"  1000  "  "  " 

"  1000  "  "  " 

"  1000  "  •'  " 

These  statistics,  while  they  do  not  show  the  percentage  of  deaths 
to  the  whole  number  of  cases  at  the  various  periods  mentioned,  serve 
to  show  that,  while  measles  is  very  prevalent  before  the  semidecennium, 
its  fatality  decreases  greatly  after  the  second  year  of  life. 

Gaunelon543  reports  the  mortality  of  measles  at  the  Hospice  des 
Enfants  Assistes  in  Paris  during  the  five  years  from  1887  to  1891  as 
follows: — 


"      1 

"      female  .  .  . 

...2.51 

1 

to     2 

years,  male  

...5.81 

1 

"      2 

"      female  .  .  . 

...5.46 

2 

"      3 

"      male  

...2.88 

2 

"      3 

"       female  .  .  . 

...2.93 

3 

"      4 

"      male  

...1.60 

3 

"      4 

"       female  .  .  . 

...1.68 

4 

"      5 

"      male  

...0.93 

4 

"      5 

"      female  .  .  . 

.  .0.96 

0  to  6  months, 

23.68 

6  "  12 

55.77 

1  "   2  years, 

53.94 

2  "   3  "  " 

27.73 

3  "   4 

13.66 

4  "   5 

6.20 

10  "  20 

nil. 

The  anomalies  of  measles  are  shown  by  Kellner,544  of  Frankfort, 
to  be  more  frequent  during  the  periods  when  the  highest  mortality 
prevails:  thus,  of  18  cases  during  the  first  year  of  life,  44  per  cent, 
were  anomalous;  of  61  during  the  second  year,  52  per  cent.;  of  84 
during  the  third  year,  34  per  cent.;  of  168  during  the  fourth  and  fifth 
years,  21  per  cent.;  of  204  during  the  sixth  to  tenth  years,  21  per  cent.; 
of  34  during  the  tenth  to  fifteenth  years,  20  per  cent.;  of  11  during 
the  fifteenth  to  twentieth  years,  18  per  cent.,  and  of  22  above  twenty 
years,  10  per  cent,  were  found  to  be  anomalous. 

According  to  Spiess,545  the  percentage  of  anomalous  cases  is  high- 
est during  the  second  year  of  life  (42  per  cent.),  after  which  it  de- 

"»  Quoted  from  Dawson  Williams  (foe.  cit.).  Gaunelon:  "La  Rougeole  a  1'Hdspice 
des  Enfants  Assistes"  (Paris,  1892). 

M  Taken  from  Thomas  (loc.  cit.). 
»*Ibid. 


RUBEOLA.  327 

creases  rapidly,  touching  the  lowest  point  (4  per  cent.)  at  the  twentieth 
year,  increasing  again  after  this  age  until  it  reaches  20  per  cent,  in 
later  life. 

Again,  the  greatest  fatality  is  met  with  in  cities,  asylums,  and 
nurseries.  According  to  Williams,  the  mortality  of  measles  seems  to 
be  unaffected  by  improved  sanitation,  in  substantiation  of  which  he 
cites  the  reports  of  the  Local  Government  Board546  of  England  and 
Wales,  showing  an  increasing  mortality  since  the  decade  ending  1880, 
while  the  principal  zymotic  diseases  which  are  more  directly  dependent 
on  sanitation  have  materially  decreased.  This  does  not  conform  to 
the  experience  of  the  present  writer.  The  death-rate  from  measles 
taken,  for  the  most  part,  from  the  worst  possible  conditions,  namely: 
the  hospitals  and  asylums  of  cities.  In  an  epidemic  which  occurred  in 
Heidelberg  Furbringer547  gave  the  death-rate  in  cases  treated  at  the 
Poliklinik  at  6.7  per  cent.,  while  in  private  practice  it  was  only  2.6 
per  cent.  In  the  Nursery  and  Child's  Hospital,  of  New  York,  Adriance 
(loc.  cit.)  reports  96  cases  with  a  mortality  of  15  5/6  Per  cent.,  and  the 
report  of  the  New  Hampshire  State  Board  of  Health  shows  that  mea- 
sles has  been  the  direct  cause  of  two  hundred  and  sixty  deaths  during 
the  past  twelve  years.548  Among  cases  well  cared  for  in  private  fami- 
lies with  healthful  surroundings  the  mortality  even  in  cities  is  far  less 
than  these  statistics  show,  while  in  the  country  the  prognosis  at  all 
ages  is  good. 

Naturally  the  depressing  influence  of  measles  on  those  of  debili- 
tated constitution  influences  the  prognosis  very  materially.  The  most 
frequent  complication,  pneumonia  excepted,  has  been  shown  to  be  tu- 
berculosis. When  this  disease  already  exists  in  a  latent  state  it  is  almost 
certain  of  assuming  an  active  if  not  rapidly  fatal  form  during  an  at- 
tack of  measles.  The  immediate  prognosis  is  dependent  largely  on  the 
organ  affected.  Th.us,  in  the  superficial  lymphatic  glands  it  is  less  fatal 
than  when  in  the  lungs  or  meninges  of  the  brain  or  spinal  cord.  Those 
having  chronic  thoracic  affections  are  especially  endangered  from  an 
attack  of  measles. 

Again,  chronic  catarrh  is  always  greatly  aggravated  during  the 
congestive  process  of  the  prodromal  stage.  When  delicate  organs  are 
involved,  as  the  structures  of  the  middle  and  internal  ear,  either  an 
impairment  OB  total  loss  of  function  or  even  death  is  imminent. 


1548  Thompson    (Theodore):    "Twenty-fourth   Annual   Report   of  the   Local   Govern- 
ment Board,  with  Supplement,"  v,  1894-95. 

547  Furbringer:   Berliner  klin.  Woch.,  1891,  S.  103. 

548  New  Hampshire  Sanitary  Bulletin,  Jan.,  1900. 


328  THE   ACUTE    EXANTHEMATA. 

The  greatest  care  should  therefore  be  taken  to  guard  strumous 
or  anaemic  children  against  the  infection  of  measles.  Those  suffer- 
ing from  chronic  otitis  or  bronchitis  should  on  no  account  be  ex- 
posed to  the  disease.  The  prognosis  is  likewise  unfavorable  in  hydro- 
cephalic  children.,  or  those  subject  to  convulsions.  Since  it  is  well 
known  that  the  mortality  of  measles  is  highest  before  the  third  year  of 
life,  children  under  this  age  should  be  assiduously  protected  from  ex- 
posure. Statistics  in  all  countries  show  conclusively  that  epidemics 
vary  greatly  in  severity.  Those  cited  by  Thomas  (loc.  cit.,  p.  114)  may 
be  given  as  bearing  especially  on  this  point.  In  1856  an  epidemic  of 
measles  broke  out  in  Lippe,  Hungary,  which  gave  a  mortality  of  50 
per  cent.  In  this  epidemic  the  prodromal  stage  was  normal,  but  after 
the  fifth  day  complications  were  frequent.  Seven  years  later,  1863, 
another  epidemic  occurred  in  the  same  town  with  a  mortality  of  only 
3  per  cent.  Xor  can  this  be  attributed  to  the  season  of  the  year  in 
which  the  epidemic  occurs.  In  1862  Karajan549  observed  an  epidemic 
of  measles  in  lower  Austria  during  the  cool  months,  which  are  sup- 
posed to  be  the  most  unfavorable,  in  which  the  mortality  was  2.29  per 
cent.,  while  in  the  same  district  during  the  following  summer  it  at- 
tained a  fatality  of  6.29  per  cent.  According  to  Voit,550  during  a 
period  of  thirty  years,  the  mortality  of  measles  during  the  winter 
months  at  the  children's  clinic  at  Wiirzburg  was  12.7  per  cent.;  dur- 
ing the  spring  months  it  was  11.5  per  cent.,  while  in  the  summer 
a  fatality  of  only  2.5  per  cent,  was  recorded.  An  epidemic  of  great 
severity  broke  out  in  Sunderland,  England,  in  1885.  in  which  Harris551 
states  that  no  previous  record  in  the  history  of  the  borough  shows 
an  epidemic  of  equal  severity.  Of  1316  known  cases,  384  deaths 
occurred,  or  over  29  per  cent.  During  the  ten  years  preceding,  the 
average  number  of  deaths  per  annum  from  measles  was  46,  and  the  per- 
centage of  mortality  was  said  to  be  very  low,  although  the  number  of 
cases  that  occurred  is  not  given.  In  1887  there  occurred  in  Liverpool 
and  vicinity  an  epidemic  which  was  considered  of  unusual  severity, 
having  a  mortality  of  15  per  cent.  In  striking  contrast  was  the  epi- 
demic which  occurred  in  the  Canary  Islands  in  1875,  in  which,  of  1123 
attacked  with  measles,  only  8  died.  Measles  seems  to  be  severe  and 
accompanied  by  an  uncommonly  high  mortality  among  certain  savage 
or  semibarbarous  peoples.  From  accounts  of  the  ravages  it  produced 


"•  Karajan,  quoted  from  Thomas  (loc.  cit.,  p.  115). 

"°Voit:  Ibid. 

B1  Harris:  Lancet,  April  30,  1887,  p.  970. 


RUBEOLA.  329 

among  the  American  Indians  one  can  appreciate  the  great  dread  the 
disease  inspired.  Since  the  introduction  of  measles  among  the  Fiji 
Islanders  in  1874  no  contagious  disease  is  said  to  be  more  feared  l>y 
the  natives  of  the  Pacific  Islands,  the  death-rate  not  infrequently  reach- 
ing as  high  as  30  per  cent.  It  is  thought  by  some  who  have  observed 
their  mode  of  managing  the  disease  that  exposure  and  surf-bathing 
account  for  the  high  mortality  there  recorded.  Doubtless  exposure  to 
inclement  weather,  at  which  time  measles  is  usually  most  prevalent, 
accounts  for  its  great  fatality  among  the  American  Indians. 

From  the  foregoing  it  is  evident  that  the  prognosis  depends  on 
numerous  influences,  which  vary  greatly  at  different  times  and  in  dif- 
ferent countries.  Unquestionably  broncho-pneumonia  complicating 
measles  is  the  cause  of  the  majority  of  deaths.  According  to  von 
Jiirgensen  (loc.  cit.},  broncho-pneumonia  complicating  measles  in 
childhood  carries  off  approximately  one-third  of  those  attacked.  On 
the  other  hand,,  measles  is  one  of  the  least  fatal  of  the  infectious  dis- 
eases (exanthemata)  when  reasonable  care  is  taken  and  when  the  en- 
vironment of  the  patient  offers  a  fair  degree  of  immunity  to  extrane- 
ous infection.  In  individual  cases  the  prognosis  is  good  when  the  fever 
diminishes  after  the  full  development  of  the  exanthem,  while  with  a 
receding  eruption,  the  temperature  remaining  high,  a  guarded  prog- 
nosis must  be  given.  With  an  irregular  elevation  of  temperature  con- 
tinuing during  the  period  of  desquamation,  tuberculosis  should  be  sus- 
pected. Croup  and  diphtheria  when  complicating  measles  likewise 
render  the  outlook  exceedingly  grave.  Diarrhoea,  when  severe,  and 
the  supervention  of  hemorrhages  either  into  the  cutaneous  lesions  or 
from  the  serous  or  mucous  membranes  should  always  be  looked  upon 
with  apprehension.  When  the  exanthem  is  confluent  over  the  whole 
body  and  assumes  a  bright  or  vivid  redness  the  termination  is  uncertain, 
and  when  it  persists  several  days  after  full  efflorescence  it  is  especially 
ominous,  and  grave  complications  may  be  expected.  According  to 
Thomas,  death  usually  takes  place  on  the  second,  and  rarely  during 
the  first,  week  of  the  disease. 

In  pregnant  women  measles  usually  follows  a  normal  course,  and 
the  prognosis  is  favorable.  When  unusually  severe  or  anomalous,  pre- 
mature expulsion  of  the  foetus  ensues,  and  death  of  the  mother  is  not 
uncommon.  This  usually  occurs  at  the  time  the  rash  appears.  Intra- 
uterine  infection  sometimes  occurs,  when  the  child  presents  an  erup- 
tion at  birth  or  the  disease  develops  soon  after.  The  greatest  danger 
to  the  mother  is  from  broncho-pneumonia  and  septicffimia. 


330  THE    ACUTE    EXANTHEMATA. 

TREATMENT. 

The  management  of  measles  is  threefold:  it  embraces,  first  of  all, 
proph}'laxis;  second,  the  task  of  conducting  the  disease  to  a  favorable 
termination;  and,  third,  the  treatment  of  such  complications  as  may 
arise. 

Prophylaxis. — It  has  been  shown  that  the  restriction  and  absolute 
control  of  measles  is  not  only  feasible,  but  highly  to  be  desired  as  a 
means  of  public  safety.  By  strict  quarantine  the  disease  has  been 
eradicated  from  certain  communities,  which  have  enjoyed  complete 
immunity  during  long  periods.  The  greatest  obstacle  to  the  segrega- 
tion of  measles  arises  from  the  fact  that  in  itself  it  is  a  mild  affection 
and  the  public  are  indifferent,  not  only  about  promptly  reporting  it 
to  the  health  authorities,  but  of  efficiently  carrying  out  the  necessary 
restrictions  against  its  spread.  In  this  country  it  is  not  long  since 
measles  was  allowed  to  prevail,  and  parents  sometimes  willfully  ex- 
posed their  children,  believing  that  sooner  or  later  they  must  have  the 
disease.  In  the  light  of  modern  sanitation  this  has  been  conclusively 
shown  to  have  caused  the  sacrifice  of  innumerable  lives  and  to  have 
destroyed  in  others  the  organs  of  hearing.  Again,  its  infectious  nature 
during  the  prodromal  stage,  before  the  family,  or  even  the  medical 
attendant,  realizes  the  danger  to  which,  others  in  the  immediate  vicin- 
ity are  exposed,  renders  its  prevention  a  perplexing  problem  for  boards 
of  health  to  solve.  Moreover,  in  the  absence,  or  at  the  beginning,  of 
an  epidemic  the  symptoms  are  often  not  sufficiently  distinctive  to 
warrant  a  prompt  and  positive  diagnosis  before  exposure  to  the  sus- 
ceptible has  already  occurred  and  an  epidemic  is  inevitable.  The 
distribution  of  literature  among  teachers  and  others  bearing  on  the 
spread  of  contagious  and  infectious  diseases  is  highly  to  be  commended, 
for  in  this  way  the  public  may  become  instructed  and  a  proper  appre- 
ciation of  its  duty  engendered.  Valuable  contributions  on  this  sub- 
ject have  been  made  by  Thomson  (loc.  cit.),  Kenwood,352  and  Baker,553 
to  whose  writings  the  student  of  preventive  medicine  may  profitably 
turn. 

The  establishment  of  boards  of  health  in  most  States  has  likewise 
done  much  to  control  the  spread  of  the  infectious  diseases. 

In  preventing  and  limiting  the  spread  of  all  infectious  diseases 
the  first  step  is  to  secure  the  intelligent  co-operation  of  the  public  at 

562  Kenwood :  Journal  of  the  Sanitary  Institute,  London,  vol.  xviii,  p.  161. 
863  Baker  (Henry  B.):  Secretary  of  the  Michigan  State  Board  of  Health,  "Reports 
and  Leaflets  on  the  Prevention  and  Restriction  of  the  Infectious  Diseases,"  etc.,  1900. 


EUBEOLA.  331 

large.  In  addition  to  the  method  suggested,  every  member  of  the  med- 
ical profession  should  realize  the  great  responsibility  resting  upon 
him,  and  lend  a  hand  by  instructing  the  people  and  reporting  to  the 
local  boards  of  health  all  cases  of  known  or  suspected  infectious  dis- 
eases at  the  earliest  possible  moment.  It  should  be  conspicuously  set 
forth  that  measles  is  contagious,  that  it  is  dangerous  to  life,  that  it  is 
one  of  the  most  frequent  causes  of  deafness,  and  as  such  is  a  constant 
menace  to  the  public  health.  The  annual  mortality  from  measles  in 
London,  according  to  Quain,534  is  nearly  5  for  every  10,000  inhabitants. 
In  1889  the  deaths  from  measles  (14,732)  in  England  and  Wales  were  5 
per  1000  inhabitants,  and  exceeded  those  from  both  scarlet  fever  (6698) 
and  diphtheria  (5368).  According  to  Bussell,555  the  deaths  from  mea- 
sles in  Glasgow  during  five  years  (1891-96)  were  three  times  as  many 
as  those  caused  by  scarlet  fever,  four  times  as  many  as  enteric  fever, 
and  only  one  infectious  disease,  whooping-cough,  was  more  destructive 
to  life.  In  the  State  of  Michigan  the  deaths  from  measles  that  were 
reported  to  the  board  of  health  were,  according  to  the  secretary's  re- 
port, several  times  as  many  as  from  small-pox,  and  for  eighteen  years 
previous  to  1888  averaged  157  per  annum.  Further  it  has  been  shown 
that  it  is  one  of  the  most  dangerous  diseases  to  which  a  child  under  five 
years  of  age  can  ~be  exposed;  that  it  is  especially  dangerous  during  teeth- 
ing, or  the  second  year  of  life,  death  often  resulting  from  inflammation 
of  the  lungs;  and  that  the  longer  a  child  can  be  protected  from  mea- 
sles the  less  liable  it  is  to  become  deaf  or  to  die  from  the  disease.  Dur- 
ing the  seventeen  years  preceding  1888,  71  per  cent,  of  all  deaths  from 
measles  in  the  State  of  Michigan  were  of  children  under  five  years  of 
age,  while  between  the  ages  of  ten  and  twenty  it  was  only  8.1  per 
cent.  In  delicate  or  strumous  children  measles  often  leads  to  consump- 
tion. It  is  not  true  that  having  the  cJuldren's  diseases  while  young 
predisposes  to  or  assures  better  health  in  after  years,  as  many  believe. 
A  leaflet  issued  and  distributed  gratuitously  by  the  Michigan 
State  Board  of  Health  (February,  1900)  gives  the  following: — 

"HOW   TO    AVOID   AND    PREVENT   MEASLES. 

"Avoid  the  special  contagium  of  the  disease.    Do  not  let  a  child 
go  near  a  case  of  measles;  this  is  especially  important  to  be  observed 


554  Quain's  "Dictionary  of  Medicine"   (London,  1883). 

555  Russell    (J.    B.):    Hand-bill    issued    for   the    Glasgow    Health    Committee,    1897. 
Quoted  from  Dawson  Williams  (loc.  cit.). 


332  THE    ACUTE    EXANTHEMATA. 

by  guardians  of  children  between  one  and  two  years  of  age.  Do  not 
permit  any  person  or  thing,  or  a  dog,  cat,  or  other  animal,  to  come 
direct  from  a  case  of  measles  to  a  child.  Unless  your  services  are 
needed,  keep  away  from  the  disease  yourself.  If  you  do  visit  a  case, 
bathe  yourself  and  change  and  disinfect  your  clothing  before  you  go 
where  there  is  a  child. 

"Do  not  permit  a  child  to  ride  in  a  hack  or  other  closed  carriage 
in  which  has  been  a  person  sick  with  measles,  except  the  carriage  has 
since  been  thoroughly  disinfected. 

"Do  not  permit  a  child  to  wear  or  handle  clothing  worn  by  a  per- 
son during  sickness  or  convalescence  from  measles. 

"Beware  of  any  person  who  has  a  cough  or  sore  throat;  do  not 
permit  a  child  to  kiss  or  take  the  breath  of  such  a  person,  nor  to  drink 
from  the  same  cup,  blow  the  same  whistle,  or  put  his  pencil  or  pen  in 
its  mouth." 

It  is  incumbent  on  teachers  and  others  having  the  care  of  children 
to  recognize  as  suspicious  the  early  symptoms  of  measles,  and  they 
should  be  informed  that  the  disease  is  contagious  before  the  rash  ap- 
pears, and  continues  so  for  three  or  four  weeks  thereafter;  that  children 
having  the  appearance  of  a  cold  in  the  head  with  smarting  of  the  eyes 
and  dread  of  strong  light  should  be  isolated,  and  if  at  school  sent  to 
their  homes,  until  the  nature  of  the  disorder  can  be  ascertained. 

Many  physicians  are  loath  to  subject  their  clients  to  the  inspec- 
tion of  the  health  authorities,  and  to  the  inconveniences  of  possible 
quarantine,  until  contagion  is  scattered  broadcast  and  prevention  is 
impossible.  The  law  in  Ohio'  and  in  most  States  compels  the  attend- 
ing physician  to  report  any  infectious  disease  within  twelve  hours  after 
becoming  aware  of  its  nature  to  the  board  of  health  within  whose  juris- 
diction such  person  is  found.  Unfortunately  the  clause  "after  becom- 
ing aware  of  its  nature"  often  means,  in  the  author's  experience,  within 
a  week  or  two  after  the  onset  of  the  disease.  Furthermore  it  is  highly 
important  that  the  executive  officer  of  the  health  board,  when  such 
exists,  should  be  well  fitted  for  the  responsible  position  he  holds  by 
thorough  training  and  broad  clinical  study.  With  the  political  meth- 
ods now  in  vogue  this  may  seem  Utopian.  At  least  the  services  of 
a  properly  qualified  person  should,  if  possible,  be  secured  in  every 
county  to  investigate  suspected  cases.  In  most  States  the  duties  of  the 
health  officer  are  formulated,  and  penalties  are  imposed  in  case  of 
neglect  or  violation  of  the  same.  The  following  is  issued  by  the  Mich- 
igan State  Board  of  Health: — 


KUBEOLA.  333 

"DUTIES  OF  THE  HEALTH  OFFICEK. 

"Some  of  the  duties  of  the  health  officer,  required  by  law,  may  be 
briefly  suggested  as  follows:  Whenever  he  has  reason  to  believe  that 
there  is  in  his  jurisdiction  a  case  of  measles,  he  should 

"(a)  Promptly  investigate  the  subject. 

"(6)  Order  the  prompt  and  thorough  isolation  of  those  sick  or 
infected  with  measles,  so  long  as  there  is  danger  of  their  communicating 
the  disease  to  other  persons. 

"(c)  See  that  no  person  suffers  for  lack  of  nurses  or  supplies. 

"(d)  Give  public  notice  of  infected  places  by  placard  on  the  prem- 
ises, and  otherwise  if  necessary. 

"(0)  Notify  teachers  or  superintendents  of  schools  concerning 
families  in  which  there  are  cases  of  measles. 

"(f)  Disinfect  rooms,  clothing,  and  premises,  and  all  articles  likely 
to  be  infected,  before  allowing  them  to  be  used  by  other  persons  than 
those  in  isolation. 

"(g)  Keep  the  president  of  his  board  of  health  and  the  Secretary 
of  the  State  Board  of  Health  constantly  informed  respecting  every 
outbreak  of  measles. 

"In  the  absence  of  regulations  made  by  the  local  board  of  health 
conflicting  therewith,  orders  by  the  health  officers  in  the  lawful  per- 
formance of  these  duties  have  the  force  of  regulations  by  the  board  of 
health. 

"Unless  otherwise  ordered  by  the  local  board  of  health,  these 
duties  are  required  of  the  health  officer  by  act  which  provides  that — 

"'Whoever  shall  knowingly  violate  the  provisions  of  Section  1  of 
this  act,  or  the  orders  of  the  health  officer  made  in  accordance  there- 
with, shall  be  deemed  guilty  of  misdemeanor,  and  upon  conviction 
thereof  he  shall  be  punished  by  a  fine  not  exceeding  one  hundred 
dollars,  and  the  costs  of  prosecution,  or  in  default  of  payment  thereof, 
by  imprisonment  not  exceeding  ninety  days  in  the  county  jail,  in  the 
discretion  of  the  court.' 

"This  penalty  seems  to  apply  to  the  health  officer  or  to  whoever 
violates  his  orders.  The  health  officer  should  also,  in  due  time,  give 
certificates  of  recovery  and  of  freedom  from  liability  to  give  measles; 
but  not  until  after  thorough  disinfection  following  complete  recovery." 

At  this  time  those  having  the  care  of  the  patient  should  be  in- 
structed either  by  circular  from  the  board  of  health  or  by  the  phy- 
sician in  charge  concerning  the  methods  to  protect  others  from  con- 


334  THE   ACUTE    EXANTHEMATA. 

trading  the  disease,  for  in  most  instances  the  execution  of  preventive 
measures  is  intrusted  to  the  family  medical  attendant.  On  the  ap- 
pearance of  measles,  therefore,  he  should  see  that  the  house  is  quar- 
antined and  that  due  notice  is  given  by  means  of  a  conspicuous  card 
on  the  door  stating  the  nature  of  the  disease.  If  there  are  other  chil- 
dren in  the  family  they  should  not  be  allowed  to  attend  school,  church, 
or  any  other  public  function;  especially  should  he  see  that  they  be 
prohibited  from  mingling  with  other  children. 

The  secretions  from  the  mouth,  nose,  and  eyes  should  be  removed 
by  soft  cloths,  which  should  be  immediately  burned  or  otherwise  disin- 
fected. The  excreta,  urine,  and  faces  should  be  disinfected  by  chlo- 
rinated lime  or  other  disinfectant  and  buried  at  least  one  hundred  feet 
away  from  any  well  or  dwelling.  When  sewer  connection  is  at  hand,  a 
disinfectant  should  be  thrown  in  after  using  and  the  basin  thoroughly 
flushed.  It  is  advisable  to  have  disinfectants  previously  prepared  and 
plainly  labeled  ready  for  use.  (See  formulary  at  end  of  volume.)  For 
water-closets,  vessels,  etc.,  lime  is  one  of  the  cheapest  and  most  efficient, 
and  may  be  prepared  as  follows:  Chloride  of  lime  (fresh),  1  pound; 
water,  3  gallons;  Mix.  A  quart  or  more  of  this  solution  may  be  used 
daily  in  a  water-closet,  basin,  vessel,  or  cuspidor.  This  may  be  diluted 
by  adding  10  gallons  of  water  to  1  gallon  of  the  solution,  when  it  may 
be  used  to  disinfect  sheets  and  other  clothing  used  by  the  patient.  It 
does  not  injure  white  clothing,  and  all  such  articles  should  be  im- 
mersed in  it  for  two  hours  before  leaving  the  room.  It  may  be  said, 
further,  that  it  is  not  poisonous  and  should  be  used  freely. 

Another  efficient  and  inexpensive  solution  is  made  by  adding,  to  1 
ounce  of  corrosive  sublimate,  1  ounce  of  permanganate  of  potash  and  8 
gallons  of  water.  It  is  non-odorous  and  is  sometimes  to  be  preferred  in 
the  sick-chamber  on  this  account.  It  is  less  efficient  than  the  chloride 
of  lime  for  cess-pools,  sink-drains,  sewers,  etc.,  and  should  not  be  used 
in  metallic  vessels.  Further,  it  is  poisonous  and  should  only  be  used 
under  the  direction  of  the  physician;  hut  its  bright-purple  color  will 
serve  to  distinguish  it.  Carbolic  acid  (1  part  to  20  of  water)  may  like- 
wise be  used  about  the  sick-chamber  when  its  odor  is  not  objectionable. 
It  is  advisable  that  articles  of  clothing,  sheets,  etc.,  be  laundried  sep- 
arately. After  leaving  the  infected  chamber  the  physician  should 
cleanse  his  hands  and  spray  his  hair,  beard,  and  clothing  with  formal- 
dehyde (5  to  10  per  cent.).  He  should,  if  possible,  avoid  coming  in 
immediate  contact  with  young  children  until  after  being  exposed  to 
the  open  air  for  an  hour  or  more.  Although  instances  are  on  record 


KUBEOLA.  335 

in  which  infection  is  supposed  to  have  been  carried  by  physicians, 
letters,  etc.,  yet  it  must  be  conceded  that,  considering  the  infrequency 
of  this  contingency,  little  danger  really  exists  when  ordinary  precau- 
tions are  taken. 

After  recovery  the  patient  should  be  thoroughly  bathed,  and  clean 
clothing  put  on,  after  which  he  should  be  placed  in  an  uninfected 
room.  The  apartments  previously  occupied  should  then  be  thoroughly 
disinfected  by  first  immersing  all  washable  articles  of  clothing,  bed- 
ding, curtains,  spreads,  etc.,  in  one  of  the  disinfecting  fluids  to  be  men- 
tioned, or  subjecting  them  to  boiling  for  half  an  hour,  or  hot  air,  230° 
F.  (105.05°  C.).  Fabrics  such  as  carpets,  books,  and  articles  of  furni- 
ture may  best  be  spread  out  and  subjected  to  the  spray  or  fumes  of 
formaldehyde,  as  given  under  room-disinfection  at  the  end  of  the  vol- 
ume. It  is  also  necessary  to  close  all  openings,  cracks,  and  other  com- 
munication with  the  outside  air  by  packing  with  cloth  or  some  other 
convenient  substance.  When  less  care  of  the  furnishings  warrants  a 
cheaper  disinfectant  the  sulphur-fumes  may  be  used,  full  directions 
for  which  will  be  found  at  the  end  of  the  volume.  Washing  with  cor- 
rosive-sublimate solution  is  equally  effective.  After  fumigating  about 
four  hours  the  room  should  be  opened,  allowing  the  freest  circulation 
of  air  possible  and  exposure  to  the  sun's  rays  for  about  twelve  hours. 
The  apartments  may  then  be  considered  free  from  danger.  When 
death  occurs,  the  body  should  be  placed  in  a  casket  as  soon  as  pos- 
sible and  2  ounces  of  20-per-cent.  solution  of  formaldehyde  sprayed  on 
the  clothing,  after  which  the  cover  is  to  be  securely  fastened.  It  is 
highly  desirable  that  but  few  persons  attend  the  funeral,  and  only 
those  who  have  previously  had  measles.  Of  great  importance  is  the 
disinfection  of  public  or  circulating  library  books.  This  is  best  done  by 
means  of  hofair  or  formaldehyde. 

Although  some  of  the  measures  recommended  may  be  more  vig- 
orous than  the  feeble  vitality  of  the  contagium  calls  for,  as  previously 
shown,  yet,  as  the  life-history  of  the  poison  is  not  known,  it  is  better 
to  err  on  the  side  of  safety.  In  the  author's  experience,  little  danger 
of  contracting  measles  exists  excepting  in  the  immediate  vicinity  of  the 
sick-chamber  or  in  the  intimate  contact  with  those  affected. 

Management  of  the  Disease. — Measles  being  a  self-limited  disease 
and  when  uncomplicated  seldom  giving  rise  to  any  serious  conse- 
quences, its  treatment  naturally  is  mainly  directed  toward  preventing 
complications. 

Efforts  have  repeatedly  been  made  to  immunize  against  measles. 


336  THE    ACUTE    EXANTHEMATA. 

Thus,  according  to  Williams  (loc.  cit.),  Thompson  inoculated  nine 
children  who  had  never  had  measles  with  fresh  serum  obtained  from  a 
blister  on  a  patient  suffering  with  the  disease.  In  one  or  two  days 
there  appeared  an  eruption  about  the  point  of  inoculation,  which  re- 
mained two  or  three  days,  bearing  a  slight  resemblance  to  measles.  In 
four  children  thus  inoculated  it  was  thought  immunity  was  established. 
Weisbecker  injected  blood-serum  from  measles  patients  under  the  skin 
without  obtaining  any  definite  results.  Hubert  and  Blumenthal  em- 
ployed serum  from  measles  patients  as  a  therapeutic  agent  in  nine  cases 
of  measles.  They  believe  it  shortened  the  duration  of  the  disease.  The 
serum  used  was  obtained  from  blood  taken  from  convalescents  and 
mixed  with  an  equal  part  of  normal  salt  solution,  to  which  1  per  cent, 
of  chloroform  was  added.  This  was  then  filtered  through  a  Berkefeld 
filter.  The  results  thus  far  have  not  given  a  positive  assurance  that 
either  immunity  or  therapeutic  value  are  to  be  obtained  by  this  means. 

Eed  light  has  also  been  used  in  measles  with  apparently  good  re- 
sults. Thus,  Chatiniere556  reports  nine  cases  of  measles  which  aborted 
in  six  hours  in  most  instances.  Not  only  the  eruption  disappeared,  but 
the  fever,  laryngeal  and  bronchial  manifestations  were  promptly  at- 
tenuated, and  recovery  was  complete  in  from  three  to  five  days  after 
the  first  symptoms  of  the  disease.  It  is  also  stated  that  the  exanthem 
directly  exposed  to  the  red  rays  of  light  was  the  first  to  disappear. 

As  soon  as  the  disease  is  recognized  the  patient  should  be  placed 
in  bed  in  a  large,  well  ventilated  room,  as  far  as  possible  away  from 
other  children,  care  being  taken  that  he  is  not  placed  in  a  direct 
draught,  and  that  the  air  entering  the  room  is  pure.  It  is  commonly 
observed  that  foul  air  tends  to  the  aggravation  of  bronchial  symptoms 
and  to  the  development  of  broncho-pneumonia.  Further,  when  the 
free  circulation  of  outside  air  is  prevented,  the  accumulation  of  car- 
bonic acid  in  the  inspired  air  retards  its  free  elimination  from  the 
blood.  Moreover,  the  greatest  care  should  be  taken  that  the  intake  of 
fresh  air  be  not  contaminated  by  smoke,  dust,  or  the  admixture  of 
emanations  from  adjoining  wards  or  decomposing  matter.  Particles 
of  dust  not  only  irritate  the  already  inflamed  mucous  membranes, 
but  serve  as  vehicles  for  various  pathogenic  micro-organisms,  against 
which  every  precaution  should  be  taken.  In  measles,  therefore,  the 
free  circulation  of  pure  air  is  imperative  and  in  larger  volume  than  is 
supplied  to  the  other  exanthemata.  As  commonly  observed,  however, 


884  Chatiniere:  Presse  Med.,  April  28,  1900. 


RUBEOLA.  337 

there  seems  to  exist  a  special  predilection  on  the  part  of  the  laity  to 
exclude  the  slightest  ingress  of  the  outside  air,  thus  inviting  the  con- 
ditions most  dangerous  to  life.  Therefore,  when  other  means  of  ven- 
tilation are  not  at  hand,  a  window  should  be  kept  partly  open  day  and 
night.  Von  Jiirgensen  (loc.  cit.}  is  of  the  opinion  that  the  danger  of 
draughts  in  measles  is  greatly  exaggerated.  Dry  air  is  likewise  more 
irritating  to  the  air-passages  than  moist  air,  besides  favoring  the  dif- 
fusion of  dust  and  various  particles  of  extraneous  matter,  which  may 
serve  as  the  carriers  of  pathogenic  bacteria.  Therefore  it  is  advisable 
to  keep  the  air  moist,  which  may  be  accomplished  either  by  keeping  a 
kettle  of  boiling  water  in  the  room  or  the  frequent  use  of  a  fine  spray. 
In  the  absence  of  a  stove,  sufficient  steam  can  be  generated  by  means  of 
an  alcohol-lamp.  For  this  purpose  the  author  has  employed  a  spray 
composed  of  a  2-per-cent.  aqueous  solution  of  formaldehyde,  which 
may  be  used  freely  about  the  chamber  and  over  the  bedclothing,  care 
being  taken  not  to  cause  undue  irritation  by  its  inhalation  in  a  too 
concentrated  form.  This  is  often  followed  by  an  amelioration  of  the 
coryza,  and  serves  as  a  disinfectant  of  the  highest  value. 

Most  rooms  are  kept  too  warm.  The  temperature  should  vary  as 
little  as  possible,  and  in  this  country  from  68°  to  70°  F.  (20.0°  to  -21.1° 
C.)  during  the  cooler  months  is  found  to  be  most  acceptable.  Another 
common  error  is  to  darken  the  room.  While  the  direct  rays  of  light 
should  not  strike  the  eye,  it  is  advisable  not  to  exclude  the  light  en- 
tirely, as  is  so  frequently  done.  If  care  be  taken  to  place  the  bed  with 
the  head  toward  the  window,  little  inconvenience  is  liable  to  be  felt  by 
the  patient.  When  the  sunlight  is  strong,  thin  curtains  may  be  drawn 
to  soften  the  sun's  rays.  At  night  there  should  not  be  a  bright  light 
in  the  room,  but  a  shade  should  be  so  arranged  as  to  produce  the  effect 
of  twilight.  'Experience  has  shown  that  cases  do  best  thus  treated,  as 
sunlight  is  known  to  be  one  of  the  most  potent  destroyers  of  disease- 
germs.  Furthermore,  no  injurious  effect  on  the  eye  is  produced.  On 
no  account  should  the  eyes  be  used  for  reading  or  other  close  work, 
until  after  complete  recovery  and  strength  is  regained.  Permanent 
injury  to  the  sight  may  otherwise  result. 

Finally,  the  essential  attribute,  cleanliness,  alike  the  prerequisite 
to  the  sick-chamber  and  hospital  ward,  must  prevail.  The  attendants 
must  be  clad  in  washable  fabrics,  and  not  only  be  cleanly  themselves, 
but  they  must  see  that  the  bed-linen  and  clothing  of  the  patient  are 
changed  at  frequent  intervals.  These  must  be  immediately  disinfected, 
and  before  leaving  the  room.  The  patient's  hody  should  be  sponged 


338  THE   ACUTE    EXANTHEMATA. 

daily  with  tepid  water.  It  is  not  enough  that  all  discharges  from  the 
nose,  eyes,  ears,  and  secretions  from  the  mouth  and  throat  be  removed 
on  soft  cloths  and  immediately  burned,  but  the  mouth  and  throat 
should  be  cleansed  by  using  some  mild  disinfectant,  such  as  a  saturated 
solution  of  chlorate  of  potash,  or  boric  acid.  For  other  applications  see 
"Addendum." 

If  marked  conjunctivitis  exists,  the  eyes  should  be  flushed  several 
times  daily  with  a  saturated  solution  of  boric  acid.  Before  handling 
the  patient  the  nurse  should  see  that  her  hands  have  been  cleansed. 
For  this  purpose  Formulae  Xos.  2  and  4  on  page  376,  will  be  found 
more  efficient  than  the  ordinary  soap.  It  is  convenient  to  have  in  the 
room  a  finger-bowl  containing  some  toilet  disinfectant,  as  Formula  Xo. 
3  at  the  end  of  the  volume.  There  should  also  be  provided  a  receptacle 
holding  about  four  gallons,  filled  to  within  eight  inches  of  the  top 
with  some  disinfecting  fluid,  such  as  chlorinated  lime,  in  which  soiled 
towels,  sheets,  pillow-slips,  night-clothes,  etc.,  may  be  immersed  be- 
fore being  sent  to  the  laundry,  or  if  more  convenient  they  may  be 
immersed  in  boiling  water  for  half  an  hour.  The  most  convenient  is  a 
solution  of  corrosive  sublimate  (1  drachm  to  a  gallon  of  water — 4.0  to 
960.0),  which  should  be  kept  in  a  crock  or  other  earthen  vessel,  care 
being  taken,  when  used  in  a  private  dwelling,  that  young  children  do 
not  come  in  contact  with  it,  and  that  it  be  plainly  and  conspicuously 
labeled  Poison. 

The  patient  should  be  kept  in  bed  until  after  desquamation  has 
taken  place,  which  is  usually  about  ten  days  from  the  first  appearance 
of  the  prodromal  symptoms.  When  practicable  it  is  advisable  to  have 
two  rooms  adjoining,  one  to  be  used  at  night,  the  other  during  the  day, 
the  room  vacant  to  be  thoroughly  cleaned  and  ventilated  ad  interim. 

Some  uncertainty  exists  in  the  minds  of  medical  men  concerning 
bathing  during  an  attack  of  measles.  While  sudden  chilling  of  the 
surface  should  be  guarded  against,  the  use  of  the  tepid  bath  is  not 
only  grateful  to  the  patient,  but  of  actual  value  as  a  therapeutic  meas- 
ure. At  the  outset  a  full  warm  bath  with  soap  should  be  given,  and, 
during  the  course  of  the  disease,  sponging,  exposing  one  part  of  the 
body  at  a  time,  or  the  full  bath,  should  be  used  as  the  judgment  of  the 
medical  attendant  may  dictate.  To  assuage  the  thirst,  which  is  usually 
complained  of,  cool  water  may  be  given  freely  and  at  frequent  intervals. 
Slightly  acidulated  beverages — such  as  weak  lemonade,  orangeade,  or 
acidulated  water  made  by  adding  a  teaspoonful  of  phosphoric  acid  to 
half  a  pint  of  water — are  usually  craved,  and  may  be  given  freely. 


EUBEOLA. 


339 


isolation  and  Disinfection  Restrict 


Measles  in  *M>i chig an,  in   /?96:-  Exhibiting  the   at/e rage 
numbers  of  cases   and  deaths  £er  outbreak:-  in  all  outlfea&s 
in  which  9 solution  and  Disinfection  were  both  JCeglecied-, 
and  in  all  outbreak*    in  which  both   were  Enforced,, 
{compiled,  in  the  ofjict  of  the  Secretary  of  the  State  Board  ef 
Health,  frojn  reports  made   ^y  local  Health  Officers.) 


r* 

J^-8 

-STtt 


isolation,   and  Disinfection 

of  I  e  c  t  e  a,  . 


Per   Outbreak  :- 
Cases.  Deaths. 


isolation  and  Disinfectiai 

£  njo 


Per    Outlreak,:- 
Cases.          Deaths. 


340  THE    ACUTE    EXANTHEMATA. 

The  diet  should  be  simple  and  suited  to  the  age  and  general  con- 
dition of  the  patient.  At  first  there  is  anorexia,  when  nourishment  in 
the  form  of  milk,  diluted  with  barley-water,  may  be  taken  with  a  cer- 
tain degree  of  relish,  or  junket,  oatmeal  gruel,  and  beef-tea  are  well 
borne.  Later  in  the  course  of  the  disease,  soft-boiled  or  poached  eggs, 
custards,  rice,  and  toast  may  be  added,  but  only  as  the  appetite  de- 
mands. Alcohol  is  seldom  indicated  in  uncomplicated  measles.  As  a 
substitute  for  alcohol,  Semmola  and  Dujardin-Beaumetz557  recommend 
1  ounce  of  glycerin  combined  with  about  8  ounces  of  water,  and  half 
a  teaspoonful  of  citric  or  tartaric  acid,  to  be  given  daily.  Von  Jiirgen- 
sen  speaks  highly  of  strong  Ehine  wine,  from  1/z  to  1  ounce  (20  to  40 
centimetres),  given  fifteen  to  thirty  minutes  before  and  after  the  bath. 
When  the  cough  is  troublesome  the  throat  may  be  freely  sprayed  with 
the  mouth-lotion  given  in  the  "Addendum,"  or  small  doses  of  the  wine 
of  ipecacuanha,  either  alone  or  combined  with  tincture  of  aconite  and 
syrup,  are  admirable.  Good  results  have  followed  the  use  of  iodide  of 
potassium.  Antipyrin  in  small  doses  is  also  recommended,  as  are  the 
bromides  of  potassium  and  sodium.  When  the  bowels  are  constipated, 
as  not  infrequently  occurs  during  the  prodromal  stage,  enemata  should 
be  given.  Diarrhrea  may  be  controlled  by  attending  to  the  diet,  by 
enemata,  or  by  small  doses  of  deodorized  opium.  This  constitutes  the 
treatment  in  a  large  majority  of  cases.  Naturally  variations  must  be 
made  according  to  the  circumstances  of  the  individual  case,  and  accord- 
ing as  the  treatment  is  conducted  in  a  well-regulated  hospital  or  in  the 
dwellings  of  the  poor.  In  the  country,  also,  some  ingenuity  on  the 
part  of  the  medical  attendant  must  be  exercised  to  meet  the  require- 
ments with  very  limited  facilities.  It  is  surprising,  however,  the  good 
results  that  may  be  attained  under  what  appear  to  be  unfavorable  cir- 
cumstances, when  the  general  principles  of  ventilation,  asepsis,  and 
segregation  are  fully  understood  and  their  value  appreciated. 

When  an  unfavorable  course  is  imminent,  one  or  more  of  the 
cardinal  symptoms  usually  give  timely  warning,  the  most  trustworthy 
being  the  temperature,  which  in  all  cases,  however  mild,  should  be 
carefully  recorded  night  and  morning.  Although  an  unusually  high 
temperature,  which  forebodes  ill,  may  subside  by  prompt  measures, 
and  the  case  go  on  to  an  uneventful  recovery,  yet  this  is  possible  in 
most  cases  only  when  prompt  measures  are  instituted.  As  pointed  out, 
the  fever  seldom  calls  for  therapeutic  measures,  but  when  the  rise  of 

587  Semmola  and  Dujardin-Beaumetz,  cited  by  Montefusco:  Rev.  des.  Mai.  de 
1'Enfance,  August,  1888. 


EUBEOLA.  341 

temperature  is  rapid  and  excessively  high,  especially  when  continued, 
it  should  receive  careful  attention,  as  it  is  not  infrequently  the  fore- 
runner of  some  grave  complication.  In  general,  the  usual  antipyretics, 
such  as  antipyrin  or  phenacetin,  are  indicated.  Only  sufficient  to  re- 
duce the  temperature  and  allay  restlessness  is  permissible.  When  the 
temperature  reaches  103°  F.  (39.4°  C.),  antithermic  measures  should 
be  used.  When  antipyrin  is  given  to  children  it  may  be  made  more 
palatable  by  the  addition  of  syrup.  The  best  of  all  methods  for  re- 
ducing bodily  temperature  is  by  means  of  ice-bags,  wet  compresses, 
sponging,  or  baths.  The  judicious  use  of  water  as  an  antipyretic  has 
long  since  been  recognized  as  a  safe  and  efficient  agent  by  the  medical 
profession,  although  the  use  of  "water  in  fevers"  has  not  altogether 
lost  its  terrors  among  the  laity.  When  the  fever  is  high  and  accom- 
panied by  delirium  or  other  nervous  manifestations,  sprinkling  cool 
water  over  the  head  and  back  of  the  neck  is  sometimes  followed  by 
marked  relief.  Cold  sponging  is  one  of  the  best  mean&  of  controlling 
a  moderately  high  temperature.  Ice-bags  made  by  inclosing  small 
pieces  of  ice  in  a  rubber  bag  and  placed  to  the  scalp  or  nape  of  the 
neck  is  even  more  prompt,  and  indicated  in  older  children  and  adults 
with  great  irritability,  convulsions,  and  delirium.  Cloths  dipped  in  cold 
water  and  applied  may  be  employed  when  ice  is  not  available.  In  very 
young  children  this  should  be  applied  for  fifteen  or  twenty  minutes  at 
a  time,  and  if  necessary  it  may  be  applied  continuously. 

When  compresses  are  used,  they  should  be  renewed  at  proper  in- 
tervals. The  full  bath  at  a  temperature  of  95°  F.,  gradually  cooled  to 
75°  or  60°  F.  (35°  to  15.5°  C.),  is  the  most  potent  means  of  controlling 
the  fever  in  malignant  measles.  It  may  be  repeated  at  frequent  in- 
tervals as  the  temperature  rises,  and  may  be  accompanied  by  ice  packs 
to  the  head.  Juhel-Renoy  and  Duponchel558  report  excellent  results 
with  cold  baths  in  the  ataxo-adynamic  forms  of  measles.  Dieulafoy559 
gave  cold  baths  in  cases  which  were  rapidly  assuming  a  malignant  form, 
in  which  improvement  began  after  the  fourth  bath.  The  suppressed 
function  of  the  kidneys  was  resumed  and  the  patients  went  on  to  recov- 
ery. According  to  Fodor,560  when  the  temperature  rises  higher  than 
102.2°  F.  (39.0°  C.)  baths  should  be  given  every  hour,  but  one  is  suffi- 
cient during  the  night.  After  immersing  the  entire  body  in  cold  water, 

658  Juhel-Renoy  and  Duponchel:  La  Tribune  M6d.,  May  15,  1890. 

658  Dieulafoy:  La  Med.  Mod.,  June  26,  1890.  Quoted  by  Crandall  in  "Sajous's  An- 
nual," vol.  iv,  p.  541. 

560  Fodor^f1^) :  Blatter  f.  klin.  Hydrother.,  etc.,  July,  1891.  Quoted  by  Crandall 
(lor.,  cit.). 


342  THE    ACUTE    EXANTHEMATA. 

the  patient  was  rubbed  with  a  sponge  and  afterward  covered  with 
towels  wrung  out  of  cold  water.  Even  after  the  subsidence  of  the 
febrile  action,  baths,  either  warm  or  cold,  may  be  continued  at  less 
frequent  intervals. 

Although  disinfectants  should  not  be  employed  indiscriminately 
to  the  general  body  surface,  yet,  when  vesicles  or  small  pustules  appear, 
they  should  be  kept  as  aseptic  as  possible.  For  this  purpose  a  saturated 
aqueous  solution  of  boric  acid,  or  preferably  an  alcoholic  solution  with 
an  excess  of  boric  acid  (Formula  No.  5  at  end  of  volume)  may  be  used. 
This  is  usually  soothing,  and  after  evaporation  leaves  the  fine  boric  acid 
powder  deeply  imbedded  in  the  skin,  and  the  odor  is  usually  agreeable 
as  counteracting  the  peculiar  and  sometimes  offensive  emanations  from 
the  patient.  It  is  not  intended  that  the  entire  surface  shall  be  treated 
in  this  way,  but  only  such  regions  as  show  a  tendency  to  the  develop- 
ment of  the  cutaneous  lesions  which  sometimes  lead  to  more  serious 
complications.  In  foundling  institutions,  however,  the  patient  and 
everything  pertaining  to  him  must  be  rendered  as  aseptic  as  possible. 
Hutinel561  recommends  that  the  child  be  given  sublimate  baths,  and 
the  nose  and  fauces  be  irrigated  several  times  a  day  with  sterilized  water 
or  a  boric-acid  solution.  With  the  attention  outlined  in  the  foregoing 
the  disease  usually  terminates  with  the  completion  of  the  desquamative 
process. 

Treatment  of  Complications. — Since  the  anomalies  and  complica- 
tions of  measles  present  the  most  serious  problems  in  the  management 
of  the  affection,  such  possibilities  should  ever  be  in  mind.  At  the  same 
time  it  should  be  understood  that  the  treatment  of  these  conditions 
does  not  differ  from  that  employed  when  measles  does  not  enter  into 
their  causation.  While  it  is  not  intended  to  enter  into  the  treatment 
of  extraneous  diseases  with  any  degree  of  completeness,  a  few  sug- 
gestions at  this  time  may  not  be  out  of  place. 

Some  writers  lay  great  stress  on  the  retarded  or  light  appearance 
of  the  exanthem.  This  is  especially  so  among  the  older  writers. 
Among  recent  writers  Larrabee562  believes  that  the  treatment  should 
be  directed  to  facilitate  the  prompt  development  of  the  cutaneous  erup- 
tion. For  this  purpose  he  advises  the  administration  of  the  iodides 
with  diaphoretics  or  the  sheet  pack  wrung  out  of  hot  water  to  which 
mustard  has  been  added.  Paulet563  regards  cocaine  (0.3  grain,  or  0.02 


M1  Hutinel:  La  Med.  Mod.,  Jan.  26,  1895. 

M2  Larrabee:  Pediatrics,  Oct.  1,  1897. 

Ms  Paulet:  New  York  Med.  Jour.,  June  5,  1897. 


EUBEOLA.  343 

gramme,  daily  to  a  child  five  years  old)  a  sovereign  remedy  in  bringing 
out  a  tardy  eruption.  Unless  there  exists  some  special  reason  for  caus- 
ing a  prompt  determination  of  blood  to  the  surface,  mild  measures — 
such  as  warm  baths  and  moderate  bed-covering — are  to  be  preferred  to 
more  radical  means,  for,  in  the  author's  experience,  no  unfavorable 
prognostic  significance  can  be  attached  either  to  the  tardy  appearance 
or  mild  character  of  the  eruption. 

The  Skin  and  Mucous  Membranes. — When  the  mild  antiseptics 
previously  mentioned  prove  inefficient,  all  purulent  accumulations 
must  be  freely  opened  and  cavities  or  secreting  surfaces  flushed  with  a 
l-to-1000  solution  of  corrosive  sublimate.  To  the  eye,  half  the  strength 
may  be  applied  once  or  twice  daily  as  indicated.  Should  ulcerative 
stomatitis  supervene,  a  pledget  of  cotton  saturated  with  a  l-to-500  solu- 
tion of  the  same  drug  may  be  applied  two  or  three  times  a  day.  It 
must  be  used,  however,  with  the  greatest  care,  and  only  by  the  phy- 
sician. Safer,  especially  in  young  children,  is  a  10-per-cent.  solution 
of  the  silver  nitrate.  In  most  cases  the  early  and  frequent  application 
of  these  will  prevent  more  radical  measures,  such  as  chromic  acid,  the 
actual  cautery,  and  other  escharotics.  The  importance  of  rendering  all 
lesions  as  aseptic  as  possible  cannot  be  too  strongly  insisted  upon. 

Laryngitis. — The  prompt  application  of  cold  to  the  throat,  when 
the  larynx  first  shows  signs  of  inflammation,  will  sometimes  avert  more 
serious  trouble.  It  should  not  be  continued  long  unless  followed  by 
marked  benefit.  When  farther  advanced,  hot  applications,  with  the 
object  of  producing  a  strong,  revulsive  action,  should  be  made.  To 
accomplish  this  a  cloth  or  napkin  folded  and  wrung  out  of  water  as 
hot  as  can  be  borne  is  placed  just  above  the  sternum.  It  must  be 
changed  as  sc-6n  as  the  temperature  lowers,  and  reapplied.  It  is  not 
advisable  to  burn  or  cause  blisters  to  form;  hence  the  second  appli- 
cation must  be  at  a  lower  temperature.  In  all  cases  a  mustard  foot- 
bath should  be  given  at  the  onset.  In  the  less  severe  forms,  and  when 
breathing  is  not  seriously  interfered  with,  these,  with  the  inhalation 
of  steam  and  the  frequent  use  of  the  spray  previously  mentioned,  usu- 
ally suffice.  When  the  laryngitis  becomes  severe  and  a  whitish  mem- 
brane appears,  or  with  the  supervention  of  dyspnoea,  the  physician 
must  bear  in  mind  the  possible  necessity  of  intubation  or  tracheotomy. 
The  bowels  should  be  freely  opened  by  castor-oil  or  small,  frequently 
repeated  doses  of  calomel.  In  robust,  full-blooded  subjects,  especially 
when  accompanied  by  congestion  of  the  face,  one  or  two  leeches  ap- 
plied to  the  neck  above  the  sternum  is  highly  spoken  of  by  Williams. 


344  THE   ACUTE    EXANTHEMATA. 

Of  all  measures,  the  steam  inhalations  are  the  most  important.  The 
apparatus  can  readily  be  extemporized;  a  tent  made  by  throwing  a 
sheet  over  the  head  of  the  bed  and  fastened  at  the  sides  will  suffice. 
The  nozzle  of  the  tea-kettle  rilled  with  boiling  water  is  then  introduced 
under  the  sheet,  which  soon  fills  the  tent  with  vapor.  Creasote  or  tur- 
pentine may  be  added  to  the  water,  or  lime-water  may  be  used.  The 
length  of  time  the  inhalation  should  continue  varies  with  the  severity 
of  the  case:  when,  mild,  from  fifteen  to  twenty  minutes  every  two  or 
three  hours,  while  in  severe  cases  it  may  be  used  almost  continuously. 
In  the  suffocative  form  an  effort  should  be  made  to  cause  a  rapid  de- 
termination of  the  blood  to  the  surface,  which  may  be  induced  by  the 
mustard  pack,  brisk  rubbing,  or  dry  cupping,  followed  by  hot  fomenta- 
tions. These  failing,  oxygen  should  be  given. 

Diphtheria. — Although  sometimes  appearing  as  a  complication  of 
measles,  diphtheria  does  not  call  for  special  consideration,  as  it  requires 
the  same  treatment  that  it  would  under  other  conditions. 

Broncho-pneumonia. — Capillary  bronchitis  is  the  most  to  be 
dreaded  of  all  the  complications  of  measles.  On  this  account  the  med- 
ical attendant  should  ever  be  on  the  alert  to  detect  the  early  symptoms 
of  the  disease.  The  principles  involved  in  its  treatment  embrace  the 
following:  To  supply  the  lungs  with  oxygen,  to  support  the  heart's 
action,  and  to  maintain  the  temperature  as  nearly  normal  as  possible. 
To  insure  the  first,  the  room  should  be  freely  supplied  with  fresh  air, 
and  the  patient's  head  and  shoulders  must  be  elevated  upon  pillows. 
He  should  not  be  allowed  to  remain  constantly  in  one  position,  and 
an  effort  should  be  made  to  free  the  lungs  from  accumulated  mucus. 
In  all  cases  the  bowels  must  receive  attention,  and  if  constipated, 
enemata  or  castor-oil  should  be  given.  It  is  important  that  the  periph- 
eral circulation  be  encouraged;  this  may  be  done  by  the  mustard  foot- 
bath and  the  mustard  jacket  to  the  chest.  The  former  may  be  made 
by  adding  2  tablespoonfuls  of  mustard  to  3  gallons  of  hot  water,  and 
the  jacket  by  mixing  1  part  mustard  to  6  parts  of  wheat  flour,  with 
sufficient  water  to  make  a  paste.  This  is  spread  between  two  layers 
of  cloth  and  applied  to  the  chest  until  the  skin  becomes  reddened. 
Holt  (loc.  cit.)  speaks  highly  of  the  oiled  silk  jacket,  which  should  be 
worn  constantly.  It  is  to  be  preferred  to  constant  poulticing,  and  is 
even  more  efficient,  besides  being  more  cleanly  and  easy  of  application. 
An  effort  should  likewise  be  made  to  encourage  deep  inspiration.  With 
a  deficient  aeration  of  the  blood,  and  its  effect  on  the  respiratory  centre, 
there  is  less  inclination  to  inspire  freely,  and  in  extreme  cases,  unless 


RUBEOLA.  345 

energetic  measures  are  taken,  death  soon  follows.  In  this  condition 
von  Jiirgensen  (loc.  cit.,  p.  1G3)  recommends  the  use  of  alternating  hot 
and  cold  douches  to  the  chest,  and  if  there  be  much  accumulation  of 
mucus  in  the  larger  tubes,  as  evidenced  by  the  appearance  of  coarse 
rales  widely  distributed  in  addition  to  the  fine  crepitations,  an  emetic 
may  be  given. 

The  following  procedure  is  also  highly  spoken  of  by  Thomas564: 
A  folded  sheet  wrung  out  of  cold  water  is  placed  under  the  patient, 
the  bed  being  protected  by  means  of  a  rubber  sheet  or  folded  blanket 
placed  underneath.  The  patient  is  quickly  wrapped  in  the  cold  sheet, 
which  causes  deep  inspiratory  movements  and  expectoration  of  frothy 
mucus.  In  addition  to  the  violent  respiratory  movements  which  it 
causes,  it  serves  to  reduce  the  temperature  and  stimulates  the  heart's 
action.  The  process  may  therefore  be  renewed  every  half-hour  until 
the  temperature  decreases  and  the  pulse  and  respirations  become  less 
frequent.  The  skin  is  then  dried  and  clean  clothing  put  on,  after 
which  the  patient  should  be  moderately  covered,  when  a  degree  of 
quiet  or  even  refreshing  sleep  frequently  follows.  This  should  be 
repeated  when  the  temperature  again  becomes  high  and  the  dyspnoea 
returns.  Of  the  emetics,  apomorphine  and  the  wine  of  ipecacuanha 
answer  best.  They  should  not  be  given  when  the  pulse  is  feeble 
and  there  is  marked  prostration  or  stupor.  Stimulants,  such  as  strych- 
nine (to  a  child  one  year  old  1/300  grain,  0.000216  gramme,  every 
three  hours),  given  hypodermically,  whisky,  brandy,  sherry  wine,  are 
now  indicated,  and  the  diet  should  be  as  nutritious  as.  possible.  It  is 
sometimes  advisable  to  give  nutritive  enemata.  According  to  Holt, 
stimulants  are  most  needed  when  the  temperature  is  low  or  falls  sud- 
denly, as  sometimes  occurs  at  the  crisis  of  the  disease,  and  should  be 
given  when  the  pulse  is  weak,  compressible,  rapid,  and  irregular.  The 
quantity  given  naturally  should  be  regulated  by  the  age  of  the  patient 
and  urgency  of  the  case,  from  l/2  to  2  ouncos  (15  to  60  centimetres) 
of  whisky  or  brandy,  diluted  with  8  volumes  of  water,  may  be  given 
daily  to  a  child  one  year  old.  As  pointed  out  by  this  author,  children 
may  be  more  easily  induced  to  take  some  of  the  sweet  wines,  such  as 
sherry  or  Tokay.  Lomikovsky565  recommends,  in  the  treatment  of  lobar 
pneumonia  associated  with  measles,  large  doses  of  digitalis.  He  has 


3iate 
i/d 


not  observed  anjfaepressing  effect  on  the  heart  following  its  use. 


684  Thomas  (loc.  cit.,  p.  124). 

566  Lomikovsky:  La  M6d.  Mod.,  Feb.  27,  1895. 


346  THE   ACUTE    EXANTHEMATA. 

When  heart-failure  seems  imminent,  trinitrin  (nitroglycerin),  in  young 
children  1/300  grain  (0.00013  gramme)  every  hour  until  four  or  five 
doses  have  been  given,  or  oxygen  holds  out  the  greatest  hope.  When 
broncho-pneumonia  appears  in  a  general  ward  or  when  there  are  other 
cases  of  measles,  it  should  be  isolated,  and  the  room  fumigated,  as  it 
is  known  to  be  communicated  from  one  to  another.  At  the  Hospice 
des  Enfants  Assist  es,  Paris,  when  cases  of  broncho-pneumonia  break 
out  in  the  measles  ward,  they  are  promptly  segregated  by  means  of 
glass  boxes,  about  three  metres  in  height,  and  sufficiently  large  to 
admit  two  beds.  These  boxes  are  kept  open  at  the  top  and  are  placed 
against  the  wall  inclosing  an  outside  window,  thus  securing  free  ven- 
tilation. Its  construction  of  glass  renders  it  less  lonesome  for  a  child. 
It  is  claimed  that  no  instances  of  outside  infection  have  occurred  since 
its  use. 

The  Nervous  System. — The  early  disturbances  of  the  nerve-cen- 
tres, such  as  convulsions,  when  not  frequent  nor  protracted,  occurring 
at  the  onset  of  the  disease,  call  for  no  special  treatment.  When  they 
occur  during  the  acme  of  the  efflorescence  accompanied  by  high  fever, 
cold  applications  should  be  applied  to  the  scalp  and  nape  of  the  neck. 
Guinon568  recommends  cold  baths,  the  water  being  gradually  cooled, 
and  the  pouring  of  cold  water  on  the  head.  Thomas  (loc.  cit.}  recom- 
mends stimulants  (wine,  benzoic  acid,  or  camphor)  in  large  doses,  and 
if  the  surface  is  cold  the  employment  of  warm  baths  and  cool  douches 
upon  the  head.  When  there  is  apathy  and  marked  congestion  of  the 
face,  in  addition  to  the  ice-bag,  leeches  may  be  applied  to  the  mastoid. 
This  is  advisable  in  very  young  children  only  when  they  are  robust, 
while  in  older  children  or  adults  free  bleeding  is  sometimes  followed  by 
the  disappearance  of  these  ominous  symptoms.  Internally,  Williams 
speaks  well  of  antipyrin  given  in  one  full  dose,  appropriate  to  the  age 
and  condition  of  the  patient,  preferably  in  the  afternoon.  When  there 
are  signs  of  adynamia  with  high  fever,  quinine  sulphate  is  indicated 
(1  to  2  grains — 0.065  to  0.2  gramme)  for  every  year  of  age,  three  times 
daily.  If  diarrhoea  be  present  the  tannate  of  quinine  in  double  the 
dose  is  to  be  preferred. 

Otitis. — The  frequency  of  inflammation  of  the  middle  ear  and  its 
serious  consequences  necessitates  special  attention  to  these  organs  in 
all  cases  of  measles.  Moreover,  much  can  be  done  to  obviate  total  or 
even  partial  loss  of  hearing,  if  accumulations  of  mucus  in  the  naso- 


Guinon:  Blatter  f.  klin.  Hydrotherapie,  July,  1891. 


RUBEOLA.  347 

pharynx  and  Eustachian  tul>es  are  encouraged  to  escape.  For  this 
purpose  frequent  gargling  with  antiseptics  and  cleansing  the  nares 
by  means  of  the  spray  should  be  employed.  In  infants  the  careful 
use  of  a  swab,  made  by  rolling  sterilized  cotton  about  a  tooth-pick 
or  probe,  dipped  in  peroxide  of  hydrogen,  the  boric-acid  solution 
previously  given,  or  other  bland  antiseptic  should  not  be  neglected. 
In  cool  weather  care  should  be  taken  that  the  fluid  is  rendered  luke- 
warm. After  cleansing  the  mucous  surfaces  within  reach,  Williams  rec- 
ommends the  application  of  an  ointment  composed  of  5  minims  of  oil 
of  eucalyptus  to  an  ounce  of  vaselin.  This  may  be  applied  with  a 
camel's-hair  pencil.  Sometimes  in  older  children  accumulations  may 
be  prevented  by  directing  the  frequent  blowing  of  the  nose,  or  by  the 
use  of  Politzer's  inflation-bag.  This  latter  should,  however,  not  be 
used  oftener  than  once  a  da}',  and  then  only  by  the  physician.  It 
should  be  discontinued  if  the  ear  becomes  painful.  To  relieve  the 
pain,  hot  applications  are  often  effectual,  or  the  introduction  of 
cocaine  or  atropine  or  the  two  combined,  of  each,  2  to  3  per  cent, 
in  water.  A  few  drops  may  be  instilled  into  the  canal  by  placing  the 
opposite  side  of  the  head  on  a  pillow  and  allowing  the  fluid  to  percolate 
about  the  drum.  As  soon  as  there  are  evidences  of  pus  accumulation, 
or  bulging  of  the  tympanum,  the  membrane  must  be  incised  without 
delay.  This  is  accomplished  by  the  head  being  firmly  held  by  an  as- 
sistant, allowing  the  light  reflected  from  a  head-mirror  to  strike  the 
drum,  when  an  opening  is  made  in  the  lower  and  posterior  segment  of 
the  membrane.  The  canal  should  then  be  flushed  with  equal  parts 
of  warm  water  and  peroxide  of  hydrogen,  repeated  two  or  three  times 
a  day.  The  eardrum  should  be  inspected  at  frequent  intervals,  lest 
it  close  up,  when  the  operation  must  be  repeated.  At  other  times  the 
membrane  ruptures  of  its  own  accord,  in  which  case  an  impairment 
of  hearing  is  liable  to  follow.  When  the  sen-ices  of  an  aurist  are 
available  it  is  always  advisable  to  intrust  this  complication  to  his  im- 
mediate care.  When  the  septic  process  invades  the  mastoid  cells,  the 
services  of  the  surgeon  should  immediately  be  secured. 

In  pregnancy,  should  a  miscarriage  occur,  the  greatest  precautions 
must  be  taken  to  guard  against  septicaemia. 

Finally,  convalescence  in  measles  is  often  protracted,  and  the  pa- 
tient must  guard  against  undue  exposure  to  inclement  weather,  over- 
fatigue,  eye-strain,  or  too  close  application  to  study.  It  is  sometimes 
necessary  to  send  city  children  into  the  country,  and,  if  signs  of  tuber- 
culosis appear,  change  of  climate  may  be  advisable. 


CHAPTEK  VII. 

RUBELLA.567 

(German  measles,508  false  measles,  rubeola  sine  catarrho, 
rubeola  notha,  hybrid  measles,  scarlatina  morbillosa,  morbiUl 
scarlatinosa,  bastard  measles,  bastard  scarlatina,  epidemic  roseola; 
French,  rubcole;  German,  rotheln,™  rubeola.) 

DEFINITION. 

A  MILD,  epidemic,  contagious,  and,  to  a  very  slight  extent,  in- 
fective, eruptive  disorder  of  short  duration,  characterized  by  the  ap- 
pearance of  a  faded  pink  or  faint-reddish,  fine  macular  eruption, 
accompanied  by  enlargement  of  the  superficial  lymphatic  glands  of  the 
neck,  and  disappearing  in  three  or  four  days.  It  is  usually  preceded 
or  accompanied  by  a  slight  congestion  of  the  fauces,  tonsils,  and  con- 
junctivae,  and,  while  presenting  in  a  minor  degree  some  of  the  charac- 
teristic fea.tures  of  both  measles  and  scarlatina,  is  in  no  way  related  to 
either.  Like  the  other  exanthemata,  it  is  self-protective,  and  immunity 
is  conferred  by  one  attack. 

Unlike  the  other  exanthemata,  rubella  seems  to  have  escaped  the 
observation  of  the  ancients,  unless  the  Arabian,  Hhamikah  or  Humak, 
employed  by  Avicenna,  refers  to  it  as  some  believe  (see  page  13).  The 
succeeding  ages  of  medical  chaos  not  only  failed  to  bring  forth  any 
new  development  in  the  class  of  affections  now  under  consideration, 
but  well-nigh  succeeded  in  obliterating  the  line  of  demarkation  be- 
tween the  clearly  defined  diseases  of  the  exanthem  group,  which  had 
already  been  established.  It  is  not  strange,  therefore,  that  an  evanes- 
cent affection  having  no  striking  features,  and  even  these  at  times 
counterfeited  by  both  measles  and  scarlatina,  should  fail  of  recognition 
until  the  beginning  of  what  might  be  termed,  despite  a  few  brilliant 
individual  exceptions,  the  renaissance  of  medicine,  about  the  middle 
of  the  eighteenth  century. 

The  disease  we  now  call  rubella,  the  Germans  rbtheln,  and  the 
French  rubeole,  first  attracted  attention,  according  to  Thomas,  in 


667  Diminutive  of  rubeola,  from  ruber,  red.  The  English  equivalent  of  the  German 
rolheln,  and  first  used  by  Veale,  of  England,  in  1866,  and  which  has  met  with  general 
acceptance  by  English  writers. 

"•^  Because  thought  to  have  been  first  described  by  German  authors. 

*"•  Diminutive  of  roth,  red  (see  page  25). 

(348) 


RUBELLA.  349 

France  and  England,  where  it  was  called  "roseola,"  although  the  first 
clear  description  of  the  disease,  according  to  Griffith,570  was  given  by 
De  Bergen,  of  Germany  (1752),  who  maintained  that  it  should  be  dif- 
ferentiated from  both  measles  and  scarlatina.571  Unfortunately  he  em- 
ployed the  term  roseola  (de  roseolis],  which  later  lost  its  specific  sig- 
nificance and  became  one  of  the  twelve  varieties  described  by  Willan. 
Orlow572  (1758),  likewise,  while  he  did  not  decidedly  advocate  its  accep- 
tation as  a  disease  sui  generis,  presented  a  clinical  picture  which  demon- 
strates his  familiarity  with  the  affection  as  we  know  it  to-day.  Then 
came  the  difficulties  of  diagnosis  resulting  from  the  absence  of  striking 
as  well  as  constant  clinical  features,  and  epidemics  were  reported  ex- 
ceeding in  virulence  that  observed  in  either  measles  or  scarlatina. 
Thus,  Formey573  states  that  between  1784  and  1796  there  died  from 
rotheln  in  Berlin  alone  1180  persons,  while  only  205  deaths  occurred 
from  scarlatina  and  103  from  measles.  He  speaks  of  the  early  forma- 
tion of  a  whitish  membrane  in  the  throat,  with  subsequent  severe 
nervous  symptoms,  such  as  coma  and  delirium.  Naturally  such  ap- 
parent errors  of  diagnosis  led  to  great  confusion  and  the  rejection  of 
rubella  as  a  specific  disease  on  the  part  of  the  majority  of  German 
physicians. 

In  England  Sydenham  (1685)  included  it  with  scarlet  fever,  as 
did  Morton  (1694),  who,  according  to  Squire,  spoke  of  scarlatina  as  a 
mild  form  of  scarlet  fever,  which  latter  affection  he  referred  to  as  "con- 
fluent measles."  Willan  (1808)  and  Bateman  (1814)  described  a 
rubeola  sine  catarrho,  which,  they  observed,  did  not  protect  from  mea- 
sles, while  it  remained  for  Maton574  (1815)  to  establish  the  fact,  based 
on  observation,  that,  while  it  is  self-protective,  it  does  not  confer  im- 
munity to  either  measles  or  scarlatina,  nor  do  these  diseases  protect 
against  rubella.  From  this  time  forth  various  opinions  were  held. 
Many— from  Henke575  in  1818,  Wunderlich576  in  1856,  to  Kostlein577 
as  late  as  1865 — maintained  that  it  was  a  modified  or  anomalous  form 
of  measles;*  others — among  whom  may  be  mentioned,  Eeil578  (1790), 

570  Griffith  (J.  P.  Crozer) :  New  York  Med.  Record,  July  2  and  9,  1887. 

571  The  author  has  been  unable  to  verify  the  claim  of  De  Bergen's  priority  of  un- 
equivocal description. 

572  Orlow:  "De  rub.  et  morbill.  discrim.,"  Progr.  Konigsb.,  1758  (Thomas). 

573  Formey,  quoted  by  Griffith  and  von  Jurgensen  (loc.  cit.,  p.  263). 

B7*  Maton:  "Med.  Trans,  of  the  Royal  Coll.  of  Physicians"  (London,  1815),  vol.  v, 
p.  149. 

575  Henke:  "Hdb.  d.  Kndrkkh.,"  1818  (Thomas). 

576  Wunderlich:  "Path.,"  2  Aufl.,  1856  (Thomas). 

577  Kostlein :  Wiener,  med.  Presse,  1868,  13. 
S78Reil:  Ibid. 


350  THE   ACUTE    EXANTHEMATA. 

Hufeland579  (1793),  Heim580  (1812),  and  Goden581  (1822)— considered 
it  a  form  of  scarlatina;  while  Hildebrand582  (1825),  Schonlein583 
(1832),  Canstatt584  (1847),  Gintrac585  (1858),  Hebra  (1865),  and  Aitkin 
(1870)  looked  upon  it  as  an  intermediate  or  hybrid  form  of  measles 
or  scarlatina,  and  still  others,  with  Jahn586  (1835),  denied  its  existence 
entirely. 

From  the  utter  lack  of  uniformity  of  opinion  as  well  as  in  nomen- 
clature, as  the  long  list  of  synonyms  attests,  little  or  no  progress  was 
made  in  assigning  rubella  its  proper  place  until  within  the  memory  of 
those  still  living.  In  fact,  until  within  the  last  two  decades  of  the  nine- 
teenth century  authors  were  still  at  variance  concerning  what  seemed 
to  be  a  perplexing  nosological  problem.  Further,  with  the  influence 
of  such  celebrated  teachers  as  Hebra,  Xiemeyer,  Henoch,  and  Fagge 
to  contend  against,  it  was  no  easy  task  to  offer  proof  sufficiently  con- 
vincing for  general  acceptance,  nor  to  place  the  specificity  of  rubella 
on  a  firm  basis.  Added  to  this  the  mild  nature  of  the  disease  and  the 
fact  that  few  patients  entered  hospitals  or  even  applied  for  medical 
aid,  and  the  comparative  infrequency  of  epidemics,  the  outlook  of 
arriving  at  any  uniformity  of  opinion  seemed  well-nigh  hopeless.  To 
the  careful  observations  and  writings  of  Homans587  (1845),  Getting588 
(1853),  Howard589  (1871),  J.  Lewis  Smith,  Hatfield,  Park,  Earle,  Ed- 
wards, Atkinson,  Griffith,  and  Hardaway,  in  America;  Alibert,  Trous- 
seau, and  Sevestre,  in  France;  and,  in  Germany,  Thierf elder,  Wunder- 
lich,  Oesterreich,  von  Ziemssen,  Laube,  and  Thomas,  we  are  indebted 
for  solving  the  nosological  problem  of  rubella  and  its  many  pseu- 
donyms, and  demonstrating  beyond  reasonable  doubt  the  specific 
nature  of  the  disease.  In  this  view  the  author  believes  the  consensus 
of  opinion  in  all  countries  is  now  in  accord. 

From  a  clinical  study  covering  a  period  of  twenty  years  the  present 
writer  has  observed  that  the  requirements  which  entitle  rubella  to  be 
classed  as  a  distinct  affection  are  sufficiently  uniform  to  warrant  the 
following  deductions: — 

679  Hufeland:  Ibid. 

880  Heim:  Horn's  Archiv  (1809),  B.  7,  and  Hufeland's  Jour.,  1812,  iii,  61. 
581  Goden,  cited  by  Griffith.    M*  Hildebrand  (vide  Thomas,  loc.  cit.). 
58:1  Schonlein:  Ibid.  »*  Canstatt:  "Handbuch,"  ii,  1847  (Thomas). 

685  Gintrac:  "Canst.  Jahresb.,"  1858,  and  Jour,  de  Bord.,  1862  (Thomas). 
886  Jahn:  Anal.  ub.  Kinderheilk.,  4,  p.  150. 

587  Cited  by  J.  Lewis  Smith:  "Med.  and  Surg.  Dis.  of  Infancy  and  Childhood" 
(Philadelphia,  1896). 

""Cotting:  Boston  Med.  and  Surg.  Jour.,  March  15,  1873. 
589  Howard:  Ibid. 


RUBELLA.  351 

First.  Rubella  is  a  mild  form  of  infection  which  always  follows  a 
benignant  course  and  first  appears  as  a  general  or  constitutional  dis- 
ease, accompanied  by  a  slight  rise  of  temperature  and  slight  feeling  of 
illness.  In  this  it  conforms  to  the  other  affections  of  this  class. 

Second.  The  local  manifestations,  while  partaking  of  the  char- 
acter of  those  observed  in  both  scarlet  fever  and  measles,  are  distinct, 
and  possess  an  individuality  which,  as  a  rule,  may  be  recognized  by  the 
trained  eye. 

Third.  While  we  have  no  exact  knowledge  of  the  cause  of  the 
disease  and  in  what  respect  the  virus  differs  from  that  of  other  diseases 
to  which  it  bears  the  closest  resemblance,  yet  we  do  know  that  it  is 
contagious,  and  always  gives  rise  to  a  like  disease:  in  short,  conforms 
to  the  type. 

Fourth.  It  occurs  but  once  in  the  same  individual,  from  which 
we  infer  that  it  is  self-protective,  while  it  affords  no  protection  to,  or 
modification  of,  measles  or  scarlatina;  nor  has  it  appeared  that  they 
offer  any  protection  against  rubella.  It  must  be  remembered,  more- 
over, that  even  mild  forms  of  the  various  exanthemata  are  self-pro- 
tective. The  fact  that  the  patient  at  some  previous  time  has  had  either 
scarlet  fever  or  measles,  or  both  of  these  affections  in  a.  well  marked 
degree,  often  leads  to  its  recognition.  Sometimes,  even  before  its  true 
nature  has  been  definitely  settled  in  the  mind  of  the  medical  attendant, 
the  disease  disappears. 

Fifth.  Like  the  other  exanthemata,  it  always  appears  in  the 
form  of  an  epidemic,  which  seems  to  bear  little  or  no  relation  to  epi- 
demics of  other  diseases,  such  as  scarlet  fever  or  measles.  It  some- 
times occurs  independently;  again,  two  or  more  of  the  epidemic 
exanthemata  prevail  at  the  same  time.  It  must  be  admitted  that  ex- 
traneous conditions  of  weather  and  possibly  of  sanitation  predispose  in 
a  like  degree  to  all.  Though  epidemics  of  rubella  seem  to  occur  at  less 
frequent  intervals  than  do  those  of  either  scarlatina  or  measles,  there 
can  be  no  doubt  that  very  many  epidemics  of  rubella  escape  recog- 
nition, and  are  regarded  as  mild  or  aberrant  forms  of  one  or  the  other 
of  the  first-named  affections.  While  the  author  believes,  with  Atkin- 
son,500 that  unless  more  exact  methods  are  adopted  in  the  study  of  the 
exanthemata  there  is  still  danger  of  endless  confusion,  and  that  the 


690  The  study  of  rdtheln  is  thus  rapidly  becoming  obscured  by  fantastic  and  motley 
embellishments,  and  there  is  reason  to  fear  that  the  resulting  confusion  will  reawaken 
the  early  skepticism  concerning  it.  Atkinson  (Zoo.  cit.,  p.  19).  Amer.  Jour.  Med.  Sciences, 
Jan.,  1887. 


352  THE    ACUTE    EXANTHEMATA. 

practice  of  relegating  all  mild  or  otherwise  anomalous  forms  of  measles 
or  scarlatina  to  rubella  is,  as  it  was  thirteen  years  ago,  far  too  prev- 
alent; yet  the  remedy  lies  in  giving  to  this  important  group  of  affec- 
tions a  more  conspicuous  position  than  it  now  holds  in  the  curriculum 
of  clinical  instruction.  This  will  be  further  considered  under  diag- 
nosis. 

SYMPTOMATOLOGY. 

As  in  the  other  exanthemata,  the  symptoms  of  rubella  may  be 
grouped  into  three  stages,  although,  on  account  of  its  mild  nature,  these 
are  even  less  clearly  defined  than  is  observed  in  the  other  diseases  of 
this  class,  and  what  may  be  termed  the  type  or  cardinal  clinical  symp- 
toms are  subject  to  great  variability.  To  this  must  be  attributed  the 
difficulty  experienced  in  the  diagnosis,  and  the  hesitancy  on  the  part 
of  some  in  ascribing  to  the  affection  a  distinctive  position. 

PERIOD  OF  INCUBATION. — From  fifteen  to  eighteen  days  usually 
elapse  after  the  reception  of  the  specific  virus  before  the  first  symptoms 
appear.  Greater  variability  is  shown  than  occurs  in  measles,  although 
it  is  generally  conceded  to  be  somewhat  longer  than  in  measles.  In 
an  epidemic  of  fifty  cases  Griffith  (loc.  cit.)  found  the  period  of  in- 
cubation to  vary  from  5  in  one  case  to  11  days  in  twenty-eight 
cases,  and  Eobinson591  regards  the  latent  stage  as  varying  from  6  to  7 
days.  Bristowe592  likewise  gives  1  week  as  the  usual  time.  The  diffi- 
culty of  obtaining  accurate  data  concerning  the  latent  stage  of  rubella 
is  ably  pointed  out  by  Thomas,  who  believes  in  a  definite  period  vary- 
ing only  within  narrow  limits,  and  offers  in  confirmation  that  members 
of  the  same  family,  after  a  presumably  simultaneous  infection,  usually 
fall  ill  at  exactly  the  same  time.  Conversely,  Griffith  considers  the 
varying  period  of  incubation  characteristic  of  the  disease,  and  there- 
fore of  diagnostic  value.  Since  it  is  impossible  to  determine  in  many 
cases  the  exact  time  of  infection,  the  short  duration  given  must  be 
looked  upon  as  at  least  marked  exceptions  to  the  rule.  On  the  other 
hand,  while  most  authors  give  from  2  to  3  weeks  as  the  usual  period, 
Klaatsch593  has  recorded  cases  in  which  even  4  weeks  were  supposed 
to  have  elapsed  before  the  first  symptoms  of  the  disease  occurred.  Dur- 
ing this  period  no  evidence  of  infection  is  present. 

PERIOD  OF  INVASION. — Unlike  measles,  this  stage  is  ill  defined, 


591  Robinson:  Med.  Times  and  Gazette  (London,  1880). 

582  Bristowe:   "Practice  of  Medicine"   (London,  1880). 

588  Klaatsch:  Zeit.  f.  klin.  Med.,  1885,  10,  1,  and  cited  by  von  Jurgensen,  p.  166. 


RUBELLA.  353 

and  in  many  cases  the  symptoms  are  entirely  overlooked,  although, 
when  the  eruption  appears,  it  is  often  recalled  that  during  the  pre- 
ceding day  a  slight  feeling  of  illness,  with  headache,  was  experienced. 
This  is  especially  the  case  in  adults.  At  other  times  the  prodromal 
symptoms  are  observed  only  a  few  hours  before  the  appearance  of  the 
exanthem,  and  some  ("Whittaker,  Hardaway)  believe  that  in  the  ma- 
jority of  cases  they  are  wholly  absent.  In  children,  according  to  the 
writer's  observation,  there  are  usually  some  mild  catarrhal  symptoms 
which  sometimes  resemble,  although  to  a  lesser  degree,  those  observed 
in  measles,  while  their  duration  is  at  most  not  longer  than  twenty- 
four  hours  instead  of  four  days  as  in  the  latter  disease.  A  suffusion 
of  the  conjunctivas  is  nearly  always  present,  although  there  is  less  pho- 
tophobia than  in  measles.  The  throat  is  usually  affected  simultane- 
ously, and  pain  on  deglutition  is  sometimes  complained  of. 

At  this  time  the  tonsils  may  be  found  swollen  and  the  fauces  in- 
jected. In  some  cases  hoarseness  and  cough  are  present.  Xo  enanthem 
has  been  observed  at  this  time,  although  the  buccal  mucosa  sometimes 
presents  a  pinkish  tint  a  few  hours  before  the  cutaneous  exanthem 
appears.  In  delicate,  neurasthenic  children  the  symptoms  may  be  even 
more  pronounced,  consisting  of  restlessness,  some  anorexia,  and  rarely 
nausea  and  vomiting.  There  may  be  shivering,  giddiness,  and  aching  of 
the  extremities.  In  one  hundred  and  nineteen  cases  von  Nymann 
noted  rigors  in  nineteen.  J.  Lewis  Smith594  observed  convulsions,  and 
Hardaway595  has  reported  a  case  in  which  this  stage  began  with  mild 
delirium.  Both,  however,  must  be  looked  upon  as  anomalous,  indi- 
cating an  abnormal  sensibility  on  the  part  of  the  patient.  There  is 
usually,  toward  th' e  end  of  this  stage,  from  two  to  twelve  hours  before 
the  eruption,  a  slight  rise  of  temperature,  which  gradually  increases 
to  100°  or  101°  F.  (38.4°  C.),  rarely  higher.  This  may  be  of  short 
duration  or  remain  until  the  acme  of  the  disease  is  reached.  In  gen- 
eral, the  presence  or  absence  of  fever  during  the  initial  stage  depends 
on,  or  at  least  is  proportionate  to,  the  concomitant  symptoms,  and, 
while  the  observation  of  the  present  writer  is  not  wholly  in  accord  with 
Atkinson890  and  Duckworth,597  that  the  short  duration  or  entire  ab- 
sence of  febrile  symptoms  previous  to  the  appearance  of  the  eruption  is 


564  Smith   (J.  Lewis),   loc.  cit. 

886  Hardaway  (W.  A.):   "Rotheln,"  in  Pevper's  "System  of  Med."   (Philadelphia, 
1885),  vol.  i. 

688  Atkinson  (loc.  cit.). 

B8T  Duckworth:  London  Lancet,  1880,  vol.  i,  395. 

23 


354  THE    ACUTE    EXANTHEMATA. 

characteristic  of  rubella,  he  believes  that,  in  the  majority  of  cases,  while 
present,  it  is  so  mild  as  to  be  readily  overlooked. 

In  regard  to  the  prodromal  fever,  Emminghaus598  states  that  the 
initial  fever  is  in  very  close  relation  with  the  intensity  of  the  other 
prodromal  disturbances.  If  the  prodromes  are  well  marked  and  the 
eruption  does  not  appear  until  the  secon '  day  or  later,  a  morning  re- 
mission is  observed,  which  gives  place  toward  evening  to  an  exacerba- 
tion accompanying  the  eruption.  When  the  prodromal  symptoms  are 
slight  and  followed  on  the  same  day  by  the  eruption,  the  initial  rise  of 
temperature  is  of  short  duration  and  occurs  just  before  the  exanthem 
appears,  in  which  case  it  may  readily  escape  observation. 

Liveing599  remarks  that  the  premonitory  fever  in  German  measles 
is  generally  mild,  is  sometimes  absent,  and  resembles  in  many  respects, 
but  not  in  duration,  that  of  common  measles;  while  Thomas  maintains 
that  no  increase  of  temperature  is  noticed  at  the  beginning  of  the  ex- 
anthem,  and  in  the  cases  observed  it  is  highly  improbable  that  such  was 
present  before  the  beginning  of  the  observation  (loc.  cit.,  p.  143). 

There  is  often  sneezing,  although  marked  coryza  I  have  never 
observed. 

The  duration  of  the  prodromal  stage  is  usually  from  twelve  to 
twenty-four  hours.  Abnormally  long  periods  have  been  observed  by 
Clauson,  Roth,  and  Balfour  (Edwards),  but  they  must  be  looked  upon 
as  either  anomalous  or  due  to  extraneous  conditions. 

PERIOD  OF  ERUPTION. — Commonly  the  affection  first  attracts  at- 
tention at  this  time,  and  in  adults  the  mottling  of  the  face  becomes 
noticeable  either  to  the  patient  or  his  friends,  and  the  physician  is 
called.  At  this  time,  in  addition  to  the  objective  symptoms  already 
noted,  there  is  a  more  pronounced  congestive  disturbance  of  the  mu- 
cous membranes  of  the  mouth  and  pharynx.  The  state  of  the  tongue 
varies:  sometimes  it  is  more  or  less  coated,  with  a  few  club-shaped 
papillae  projecting,  these  being  especially  well  marked  at  the  tip.  It 
is  not  so  thickly  coated  as  in  measles,  nor  so  red  as  in  scarlatina.  At 
first  the  mucous  membrane  of  the  buccal  cavity  may  be  little  changed; 
soon,  however,  it  becomes  erythematous.  This  is  best  seen  on  the  soft 
palate  and  uvula,  which  frequently  present  punctate,  reddish  macula, 
suggestive  of  those  observed  in  measles  during  the  prodromal  stage, 
except  that  they  are  lighter  in  color,  are  smaller,  and  the  characteristic 
bluish-white  dots  are  absent.  The  skim-milk  or  bluish  tint  of  the 


588  Emminghaus:  In  Gerhardt's  "Handbuch,"  a.  a.  O.,  p.  351. 

588  Liveing  (Robert):  "Hand-book  of  Skin  Diseases"  (London,  1887),  p.  6. 


RUBELLA.  355 

buccal  mucous  membrane  observed  in  measles  is  replaced  by  a  pinkish 
tint,  which  becomes  darker  as  the  eruption  on  the  skin  develops. 

The  writer  has  never  observed  anything  especially  distinctive  in 
the  mucous  membranes  of  the  mouth  or  throat,  although  some  have 
endeavored  to  describe  an  enanthem  peculiar  to  this  disease.  Accord- 
ing to  von  Jiirgensen,600  at  the  onset  changes  may  be  seen  in  the  mu- 
cous membrane  of  the  palate  and  pharynx  which  correspond  to  those 
observed  in  measles,  and,  while  they  are  not  identical  with  the  latter, 
they  approximate  as  closely  as  do  the  cutaneous  disturbances  in  the 
two  affections.  Emminghaus001  in  some  cases  observed  changes  in  the 
mucous  membrane  of  the  palate,  which  presented  somewhat  similar 
lesions  to  those  observed  on  the  skin;  at  least,  they  were  of  a  reddish 
color,  somewhat  round,  and  had  a  circumscribed  margin.  Gerhardt602 
does  not  distinguish  between  the  enanthem  of  rubella,  and  that  of  mea- 
sles. It  must  be  mentioned  that  both  of  these  writers  are  strong  ad- 
vocates of  the  specific  nature  of  rubella.  In  a  report  of  one  hundred 
and  fifty  cases  Griffith  found,  almost  without  exception,  the  upper  por- 
tion of  the  anterior  pillars  of  the  fauces  congested,  and  the  tonsils 
swollen.  A  diffuse,  even  redness  of  the  throat  either  limited  in  extent 
or  wide-spread  was  also  rarely  absent.  In  a  few  instances  an  eruption 
of  small,  yellowish-red  or  brownish-red  spots  of  pin-head  size  was 
visible  over  the  soft  palate,  uvula,  and  inner  surface  of  the  cheeks. 
Forchheimer603  describes  what  he  considers  a  characteristic  enanthem 
in  rubella,  which  appears  simultaneously  with  the  exanthem  and  re- 
mains from  twelve  to  fourteen  hours.  Its  favorite  location  is  on  the 
soft  palate,  sometimes  extending  to  the  hard  palate.  It  consists  of 
small,  discrete,  dark-red,  but  not  dusky,  papules,  which  soon  disappear, 
leaving  no  trace  behind.  The  rest  of  the  mouth,  according  to  this 
author,  may  or  may  not  be  congested. 

According  to  Kehn,604  simultaneously  with  the  cutaneous  exan- 
them similar  lesions  may  be  observed  in  the  conjunctivas,  the  mucosae 
of  the  nasal  and  buccal  cavities,  the  pharynx,  and  especially  on  the  soft 
palate.  Subsequently  he  observed  swelling  of  the  lymphatic  glands, 
followed  by  the  cutaneous  efflorescence.  Thomas  believes  that,  next 
to  the  skin,  the  mucous  membranes  of  the  air-passages  and  of  the 

800  Von  Jurgensen  (loc.  clt.,  p.  270). 

601  Emminghaus:   "Jahrbuch  f.  Kinderheilkunde,"  B.  19,  H.  1,  p.  58. 

802  Gerhardt:  "Lehrbuch  d.  Kinderkrankheiten,"  4  aufl.   (Tubingen,  1881). 

803  Forchheimer:  Article,  "German  Measles,"  "Twentieth  Century  Practice  of  Med- 
icine" (New  York,  1898),  vol.  xiv,  p.  183. 

«°*Rehn:   "Jahrbuch  fur  Kinderheilkunde,  N.  F.,"  B.  29,  S.  282. 


356  THE   ACUTE    EXANTHEMATA. 

buccal  and  pharyngeal  cavities  present  the  most  noteworthy  symptoms. 
Thus,  catarrh  of  the  former,  while  less  intense  than  in  me:  les,  is  sel- 
dom wholly  absent,  so  that  coughing  and  sneezing  are  among  the  most 
constant  symptoms  at  the  beginning  of  the  disease.  His  observations 
concerning  the  mucous  membranes  of  the  mouth  and  throat  confirm 
what  has  previously  been  said. 

While  the  congestion  seems  to  be  exaggerated  about  various  foci, 
it  is  by  no  means  limited  to  well  defined  spots,  nor  does,  it  conform  to 
the  typical  picture  of  the  cutaneous  exanthem.  More  frequently  the 
only  symptoms  referable  to  the  mucous  surfaces  are  at  first  a  uniform 
erythema  of  the  soft  palate,  and  to  a  less  extent  the  pharynx,  and  some- 
times congestion  and  moderate  swelling  of  the  tonsils.  As  the  cutane- 
ous eruption  develops,  the  mottling  of  the  mucous  surface  becomes 
more  apparent  and  sometimes  the  color  is  intensified  in  certain  small 
areas,  which  lend  an  appearance  quite  suggestive  of  the  cutaneous 
efflorescence,  although  never  forming  the  well  defined  lesions  nor  the 
intervening  background  approximating  the  normal  color,  as  in  the 
latter. 

Of  more  importance  from  a  diagnostic  point  of  view,  and  withal 
one  of  the  most  constant  symptoms  of  rubella,  is  the  enlargement  of 
the  superficial  lymphatic  glands.  (See  Plate  XLI.)  This  may  usually 
be  detected  at  an  early  stage,  and,  as  Thierfelder605  remarks,  swelling  of 
the  subauricular  and  superior  jugular  lymphatic  glands  may  be  looked 
upon  as  a  constant  prodromal  symptom.  According  to  Atkinson,609 
enlargement  of  the  superficial  lymphatic  glands  of  the  neck  may  be 
the  most  striking  symptom,  and  sometimes  attracts  attention  several 
days  before  the  beginning  of  the  eruption,  while  Emminghaus607  says 
it  is  very  frequently  present  to  a  slight  extent  and  may  subside  even 
before  the  eruption  appears.  My  own  notes  of  cases  show  adenopatby 
in  96  per  cent.,  of  which  the  maxillary  and  superficial  or  post-cervical 
were  the  most  frequently  involved;  next  the  occipital,  posterior  and 
anterior  auricular;  and  sometimes  the  superficial  inguinal,  axillary, 
and  the  epitrochlear.  In  the  neck  the  inflammation  may  be  sufficiently 
severe  to  interfere  with  free  movement,  and  in  two  or  three  instances 
it  has  given  rise  to  marked  oedema  of  the  surrounding  parts.  In  no 
instance  has  suppuration  taken  place.  The  involvement  of  the  various 


06  Thierfelder:  Greifsw.  Med.  Beitr.,  B.  2,  Ber.,  p.  14,  1864. 
*°*  Atkinson  (lop.  cil.,  p.  23). 

807  Emminghaus:  In  Gerhardt's  "Handbuch,"  p.  351.     Also  quoted  by  Atkinson  and 
von  JQrgensen. 


PLATE  XLI. 


XLI 

RUBELLA— showing  a  typical  eruption  with  enlargement  of  the 
post-cervical  lymphatic  glands. 


Jb/t*  RMc&rnjgc  aSans,M  Riil, 


RUBELLA.  357 

groups  of  lymphatic  ganglia  is  coincident  with  the  regional  disturbance 
in  the  skin  and  mucous  membranes. 

From  the  literature  of  this  subject  it  may  be  seen  that  there  is  a 
unanimity  of  opinion  concerning  the  glandular  enlargement  which  is 
quite  unusual  in  regard  to  the  other  symptoms  of  this  disease.  Eustace 
Smith,608  however,  states  that  it  is  only  seen  in  some  epidemics,  and 
Kassowitz009  observed  adenopathy  only  in  one-third  of  his  cases.  The 
spleen  remains  unaffected. 

The  Skin. — By  far  the  most  striking,  as  well  as  the  most  constant 
feature  of  the  disease  is  the  eruption  on  the  skin.  This,  in  the  majority 
of  cases,  constitutes  the  only  symptom  that  attracts  attention,  and  with- 
out which  the  affection  would  be  unrecognizable.  Like  variola  and 
measles,  the  eruption  in  rubella  first  appears  on  the  face  and  scalp,  and 
some — with  Emminghaus,  Edwards,  and  Cuomo610 — have  observed  a 
slight,  more  or  less  uniform  efflorescence  immediately  preceding  the 
true  eruption.  This  I  have  never  encountered,  and  believe  it  should  be 
looked  upon  as  a  very  rare  exception.  The  eruption  makes  its  appear- 
ance in  the  form  of  faint  pinkish  macula?,  at  first  discrete,  but  some- 
times becoming  more  or  less  confluent  within  a  few  hours.  Xext,  ths 
neck  and  upper  part  of  the  trunk  become  involved,  after  which  the 
eruption  spreads  out  over  the  whole  trunk  and  the  upper  and  lower  ex- 
tremities in  the  order  named.  The  palms  and  soles  partake,  though  to 
a  less  extent,  in  the  general  efflorescence.  From  one  to  two  days  are 
usually  occupied  in  completing  the  process  of  extension.  The  eruption 
attains  its  full  development  within  from  ten  to  fourteen  hours  on  any 
particular  part,  so  that  the  maxima  in  various  regions  do  not  occur 
at  the  same  time,.  Thus,  the  eruption  has  already  begun  to  fade  on 
the  face  before  it  is  fully  developed  on  the  trunk,  and  it  usually  has 
well-nigh  disappeared  on  the  face  before  the  legs  are  involved.  Un- 
less the  case  is  seen  at  a  very  early  stage,  the  face  may  appear  to  have 
escaped.  Hardaway  very  properly  lays  great  stress  on  this  feature  as 
a  valuable  means  of  distinguishing  rubella  from  measles.  When  the 
maximum  development  is  reached  the  individual  lesions  are  sometimes 
perceptibly  elevated,  and  in  size  vary  from  a  pin-head  or  lentil  to  a 
small  bean.  They  are  often  slightly  elongated  or  irregularly  round  in 
shape,  with  an  ill-defined  border,  and  disappear  completely  on  pressure. 


908  Smith   (Eustace):    "Diseases  of  Children"    (New  York,  1884),   p.   31. 

608  Kassowitz :   "Transactions  Internal.   Med.  Cong."   (London,  1881),  vid.  iv,  p.  10. 

610  Cuomo:  Gior.  internaz.  d.  sci.  med.  (Napoli,  1884),  vi,  p.  529. 


358  THE    ACUTE    EXANTHEMATA. 

Unlike  measles,  they  show  no  tendency  to  form  groups,  clusters,  or 
crescents,  and  in  some  cases  manifest  a  feebler  predilection  to  coalesce. 
Sometimes,  however,  when  confluent,  they  extend  at  the  periphery, 
coalesce,  and  form  extensive  areas,  when  the  resemblance  to  scarlatina 
may  lead  to  an  error  in  diagnosis. 

Usually  the  plaques  thus  formed  are  found  only  on  certain  parts, 
while  on  the  remaining  portions  of  the  body  the  eruption  presents 
the  more  usual  appearance.  The  color  is  always  lighter  than  that  ob- 
served in  scarlet  fever,  and  in  a  strong  light  the  slight  elevations  which 
correspond  to  the  original  lesions  may  be  discerned.  Further,  the 
eruption  is  fairly  uniform  in  color  and  may  be  described  as  of  a  faded 
rose  or  pink  tint,  never,  in  my  experience,  presenting  the  fiery  red  of 
scarlatina  nor  the  dusky,  bluish  red  of  measles.  Ordinarily  the  erup- 
tion bears  the  closest  resemblance  to  measles,  but  when  the  lesions  are 
small  and  confluent,  as  sometimes  happens,  its  resemblance  to  scar- 
latina may  be  quite  striking.  Again,  the  rash  may  be  morbilliform; 
that  is,  large  and  discrete  on  some  parts,  and  confluent,  or  scarlatini- 
form,  on  others.  These  variations,  which  the  writer  has  many  times 
observed,  sometimes  give  rise  to  much  uncertainty  in  diagnosis,  and 
undoubtedly  have  retarded  the  general  recognition  of  the  disease.  It 
must  be  borne  in  mind  that  the  eruption  is  not  always  uniform,  and 
different  cases,  as  well  as  different  epidemics,  vary  considerably.  There 
are,  in  addition,  atypical  and  anomalous  forms,  in  which  a  correct  diag- 
nosis would  scarcely  be  arrived  at  were  it  not  for  other  cases  in  the 
neighborhood  which  conform  more  closely  to  the  usual  type. 

In  the  development  of  the  exanthem  many  changes  may  be  noted 
in  the  appearance  of  the  rash.  Thus,  at  first  the  spots  offer  a  feeble 
contrast  to  the  intervening  unaffected  skin;  soon,  however,  they  ac- 
quire a  brighter  color  and  more  definite  form.  Each  spot  is  surrounded 
by  an  areola  which  renders  the  centre  darker,  while  the  margin  is  less 
clearly  defined.  The  eruption  is  most  abundant  on  tbe  face,  chest, 
back,  and  nates,  and  in  some  cases  has  seemed  to  be  aggravated  by  local 
irritation,  as  from  bands  of  clothing,  garters,  and  warmth.  In  this 
respect  it  resembles  variola.  Haemorrhages  into  the  lesions  have  been 
observed  (Dunlap),  but  they  are  exceedingly  rare.  (Edema  of  the  face 
occurring  coincidently  with  the  eruption  is  recorded  by  Douglas  and 
Griffith. 

The  objective  symptoms  are,  therefore,  a  melange  representing 
both  those  of  measles  and  scarlatina,  with  a  preponderance  at  times  of 
one  or  the  other,  yet  always  adhering  to  the  type  formed  by  the  blend- 


PLATE  XLII. 


PLATE  XLII. 


Rubella,    showing  Well-Marked    Eruption    at   its   Height   on   the    Back. 


RUBELLA.  359 

ing  of  the  two.  This  in  no  sense  is  to  be  construed  as  relating  to  the 
etiology  of  the  disease  nor  as  militating  against  its  independent  nature. 

Subjective  symptoms  are  almost  entirely  absent  in  a  great  many 
cases.  When  present  they  are  of  a  mild  nature,  and  it  is  with  difficulty 
that  patients  are  retained  within  doors  during  the  whole  course  of  the 
disease.  With  the  full  development  of  the  exanthem  the  mucous  mem- 
branes begin  to  assume  their  normal  appearance;  sometimes  the  throat 
remains  congested  and  the  catarrh  of  the  upper  air-passages  remains 
for  a  week  or  more;  but  this  is  the  exception,  and  usually  the  normal 
condition  is  reached  before  the  disappearance  of  the  exanthem. 

The  Temperature. — It  is  to  be  expected  that  much  difference  of 
opinion  should  prevail  concerning  the  presence  or  absence  of  fever  in 
rubella,  as  so  many  extraneous  influences,  such  as  digestive  disturb- 
ances and  inflammation  of  the  mucous  and  serous  membranes,  are  liable 
to  modify  the  temperature  and  thus  render  it  unduly  high.  Different 
epidemics  also  seem  to  vary  in  this  particular;  moreover,  still  greater 
influence  must  be  attributed  to  the  previous  health  and  sanitary  sur- 
roundings of  the  patient.  Again,  in  conformity  with  the  class  of 
eruptive  fevers,  a  slight  rise  of  temperature  must  be  looked  upon  as 
characteristic  of  the  disease.  As  with  the  early  efflorescence  of  syph- 
ilis, so  here,  a  slight  rise  of  temperature  is  invariably  present.  The 
experience  of  most  authors  is  sufficiently  conclusive  in  this  particular, 
but  statements  vary  as  to  the  time  and  degree  of  fever  present.  Ac- 
cording to  Emminghaus,  when  the  initial  fever  is  not  detected,  the  tem- 
perature curve  may  not  be  noticeable  until  the  acme  is  reached,  or  the 
crisis,  followed  by  an  oscillation  just  above  or  even  below  the  normal, 
terminates  the  fever.  When  the  fever  continues  throughout  the  course 
of  the  disease,  it  shows  a  remittent  character  and  terminates,  either  by 
crisis  or  lysis,  within  from  two  to  four  days.  The  highest  point  of  the 
curve  never  coincides  with  the  maximum  of  the  eruption  on  any  part 
of  the  body.  Thus,  the  temperature  curve  has  not  reached  the  highest 
point  when  the  region  first  attacked  has  reached  its  maximum,  while 
the  curve,  with  slight  exacerbations,  has  already  returned  to  the  nor- 
mal line  before  the  eruption  on  the  part  of  the  body  last  to  be  affected 
has  attained  its  maximum  development.  Should  the  temperature  again 
rise  above  the  initial  curve,  a  relapse  or  some  complication  may  be  ex- 
pected. The  cases  recorded  by  Edwards  (loc.  cit.,  p.  694)  presented  a 
rise  of  temperature  during  the  eruptive  stage  ranging  from  1  to  3 
degrees,  and  sometimes  showing  even  103°  or  104°  F.  (39.4°  to  40° 
C.),  which,  as  a  rule,  corresponded  to  the  severity  of  the  eruption. 


360  THE    ACUTE    EXANTHEMATA. 

Further,  the  temperature  curve  was  very  variable,  sudden  elevations 
with  equally  sudden  falls  being  not  infrequent,  and  in  some  cases 
only  a  fraction  above  the  normal  was  recorded  throughout  the  entire 
course.  On  the  other  hand,  Thomas  observed  no  fever  during  the 
whole  course  of  the  disease  in  a  majority  of  his  cases,  while  in  some 
there  was  an  initial  rise  of  temperature  which  either  disappeared  on 
the  second  day  of  the  eruption  or  continued  until  the  third  day,  when 
it  usually  ended  abruptly  by  crisis.  Of  119  cases  von  Xymann611  failed 
to  detect  any  appreciable  rise  of  temperature  in  58,  and  in  the  remain- 
ing 61  cases  the  temperature  ranged  as  follows: — 

In  39  cases  the  highest  recorded  was  100.4°  F.   (38.0°  C.). 

"    14       "        "  "  101.3°  F.   (38.5°  C.). 

"      6       "        "  "  102.2°  F.   (39.0°  C.). 

"      2       "        "  "  103.1°  F.   (39.5°  C.). 

Von  Jiirgensen  (loc.  cit.,  p.  269)  says  that  very  often  during  the 
whole  course  of  the  disease  no  rise  of  temperature  can  be  detected,  and 
that  when  present  it  is  of  short  duration  and  never,  unless  due  to  com- 
plications, remains  longer  than  four  days.  This  view,  according  to 
Griffith,  is  held  by  Wunderlich,  Vogel,  Earl,  and  Picot. 

It  must  be  conceded  from  the  foregoing  that  the  temperature  is 
subject  to  great  variations,  and  while  fever  is  present  in  most  cases  it 
cannot  be  considered  as  in  any  way  characteristic  of  the  disease.  It 
seldom  rises  above  100°  or  102°  F.  (37.7°  to  38.8°  C.),  which  may  be 
considered  the  rule,  and  it  returns  to  the  normal  even  before  the  com- 
plete disappearance  of  the  eruption. 

The  pulse  and  respiration  are  not  perceptibly  affected  in  rubella, 
and  correspond,  for  the  most  part,  to  the  temperature  curve.  Liveing 
records  a  pulse-rate  of  144  with  a  temperature  of  100.3°  F.  In  two 
of  Griffith's  cases,  with  moderate  fever,  the  pulse-rate  was  150. 

The  Urine. — As  a  rule,  no  changes  in  the  urinary  secretion,  aside 
from  those  usually  observed  in  slight  febrile  conditions,  are  present. 
Although  slight  albuminuria  has  been  recorded  by  Liveing,  Edwards, 
Hatfield,  and  others,  it  must  be  admitted  to  be  of  uncommon  occur- 
rence, and  seldom  of  serious  import. 

THE  PERIOD  OF  DESQUAMATION  is  more  or  less  coincident  with 
that  of  the  eruption.  After  attaining  full  maturity  the  individual 
lesions  rapidly  fade,  leaving  a  faint  fawn  color  or  yellowish,  macular 
or  "marbled"  appearance  of  the  skin.  This,  it  may  be  noted,  is  not 


811  Von  Nymann,  quoted  by  von  Jiirgensen. 


RUBELLA.  361 

always  present,  and  usually  is  not  sufficiently  marked  to  attract  atten- 
tion unless  especially  looked  for.  As  previously  described,  this  goes 
on  in  successive  periods  over  different  parts  of  the  body  from  above 
downward,  so  that  the  process  is  entirely  completed  on  parts  first  at- 
tacked, before  desquamation  has  well  set  in  on  the  regions  last  in- 
vaded. Properly  speaking,  therefore,  there  is  no  stage  of  desquama- 
tion that  can  be  applied  to  the  disease  as  a  whole,  but  only  to  its 
regional  development.  This  begins  from  six  to  twelve  hours  after  the 
efflorescence  appears.  The  time  occupied  in  the  whole  eruptive  and 
desquamative  processes  varies  from  two  to  four  days.  This  is  subject 
to  great  variation,  however,  as  shown  in  von  Xymann's  119  cases  as 
follows:  From  the  outbreak  to  the  complete  disappearance  of  the  erup- 
tion it  was 


1  day     in  10  cases 

(  8.40  per  cent.). 

2  days    "   29 

(24.36     "       "     ). 

3      "       "   31       " 

(26.65     "       "     ). 

4      "       "   33      " 

(27.73     "       "     ). 

5      "        "    12       " 

(10.08     "       "     ). 

6      "       "3       " 

(  2.52     "       "     ). 

7      "       "1  case 

(  0.55     "       "     ). 

Abnormally  long  periods  have  been  reported  by  Liveing — eight  to 
ten  days  (Atkinson),  and  Edwards — fifteen  days.  They  are  rare 
anomalies.  In  100  cases  the  writer  last  quoted  found  the  eruptive 
processes  were  completed  in  an  average  of  five  days.  This  is  a  longer 
average  than  in  the  cases  which  have  come  under  the  author's  observa- 
tion. 

As  a  rule,  there  is  much  less  desquamation  than  is  observed  in 
scarlatina,  and  in  most  cases  it  is  almost  imperceptible.  On  the  palms 
and  soles  the  flakes  are  larger  and  therefore  more  noticeable  than  on 
other  parts  of  the  body,  where  exfoliation  takes  place  in  the  form  of 
branny  or  furfuraceous  scales.  It  is  usually  most  abundant  on  the 
face  and  neck,  and  is  especially  noticeable  about  the  nose^.  Itching  is 
sometimes  troublesome. 

COMPLICATIONS  AND  SEQUELS. 

In  a  large  majority  of  cases  rubella  is  neither  accompanied  by  com- 
plications nor  followed  by  sequela?,  and  with  normal  health  preceding, 
and  surroundings  conducive  to  the  same,  it  may  be  considered  free 
from  the  dangers  incident  to  both  scarlet  fever  and  measles.  On  the 
other  hand,  it  is  to  be  remembered  that  even  trivial  deviations  from 
the  normal  sometimes  incite  or  even  give  rise  to  various  diseases  which 


362  THE    ACUTE    EXANTHEMATA. 

may  have  lain  dormant  or  to  which  a  strong  predisposition  exists. 
Therefore  it  is  not  surprising  that  a  mild  affection  like  rubella  should 
in  some  instances  act  as  an  exciting  factor  to  the  long  list  of  diseases 
which  have  been  from  time  to  time  ascribed  to  it.  In  asylums,  homes 
for,  children,  and  in  thickly  settled  tenement-house  districts  of  cities 
the  greatest  danger  naturally  exists.  Edwards  (loc.  cit.,  p.  697)  men- 
tions pneumonia  as  occurring  three  times  in  a  series  of  one  hundred 
cases,  while  Griffith  reports  it  twice  in  one  hundred  and  fifty  cases. 
The  former  likewise  reports  several  cases  of  severe  bronchitis  and  one 
of  pleurisy.  Other  observers  have  likewise  encountered  bronchitis  and 
pneumonia.  Next  to  the  respiratory,  the  digestive  tract  seems  to  be 
most  affected,  and  Edwards  has  recorded  about  40  per.  cent,  of  cases 
having  some  form  of  gastro-intestinal  irritation.  This,  the  author 
quoted  admits,  is  out  of  the  common,  and  ascribes  it  to  the  bad 
hygienic  surroundings  and  the  severity  of  the  epidemic.  Abscess 
of  the  submaxillary  lymphatic  glands  is  reported  by  Golson612;  naso- 
pharyngeal  catarrh  and  permanent  swelling  of  the  tonsils  by  Metten- 
heimer613;  and  ciliary  blepharitis  and  otorrhoea  by  Hardaway.814  Most 
of  these  instances  are  generally  conceded  to  be  quite  unique  in  the 
history  of  the  disease.  They  indicate,  however,  the  catarrhal  character 
of  the  complications  most  liable  to  arise,  and  in  strumous  children, 
with  a  pre-existing  naso-pharyngeal  catarrh,  serious  impairment  of 
hearing  might  readily  follow. 

Relapse. — In  this  respect  rubella  does  not  differ  from  the  other 
exanthemata.  Edwards  observed  a  relapse  on  the  fourth  day  and  an- 
other on  the  twentieth  day  after  the  initial  eruption.  Griffith  noted  a 
relapse  in  three  instances,  one  occurring  on  the  eleventh  day,  and  the 
others  after  an  interval  of  nearly  three  weeks.  Other  cases  are  on 
record,  most  of  which  took  place  within  a  fortnight  or  three  weeks 
after  the  primary  attack.  The  second  attack  does  not  seem  to  differ 
in  any  particular,  excepting  that  the  prodromal  symptoms  are  wholly 
absent.  A  second  attack — that  is,  a  reinfection — of  rubella,  according 
to  Hardaway,  has  never  been  reported. 

PATHOLOGY. 

On  account  of  the  mild  and  evanescent  character  of  rubella  little 
attention  has  been  given  to  its  pathology.  Thomas  enters  at  length 

812  Golson:  "Transac.  Med.  Assoc.  Alabama,"  1883. 
41*  Mettenheimer:  Jour.  f.  Kinderk.,  1869,  llii. 
•"  Hardaway  (loc.  cit.). 


EUBELLA.  363 

into  the  usual  changes  observed  in  the  skin,  but,  aside  from  the  state- 
ment that  the  efflorescence  is  due  to  capillary  hyperaamia  of  the  papil- 
lary bodies  and  uppermost  layers  of  the  derma,  giving  rise  in  some  in- 
stances to  slight  exudation,  does  not  enter  into  any  further  histological 
findings.  Both  Formad  and  Edwards  describe  micrococci  in  the  blood 
in  some  cases  of  rubella,  but,  as  similar  bodies  have  been  observed  by 
Keating615  and  others  in  measles,  their  etiological  role  is  uncertain. 
Therefore  it  must  be  admitted  with  our  present  knowledge  that  little 
or  nothing  is  known  as  to  the  histological  changes  of  rubella,  nor  of 
the  active  principle  which  gives  rise  to  the  disease. 

ETIOLOGY. 

Our  knowledge  of  the  development  of  rubella  as  a  distinct  disease 
must  still  be  looked  upon  as  being  in  a  rudimentary  stage,  and  not 
until  the  specific  virus  is  revealed  can  very  definite  or  dogmatic  state- 
ments be  made  concerning  its  causation.  As  in  other  diseases  of  this 
group,  much  may  be  gained  from  a  careful  study  of  clinical  observa- 
tions, and  on  this  we  must  rely  until  more  exact  methods  are  forth- 
coming. 

Foremost  is  the  epidemic  nature  of  the  disease:  a  more  marked 
feature  than  in  either  measles  or  scarlatina.  The  observation  of  Ed- 
wards, who  cites  Liveing,  Thomas,  and  Meigs,  coincides  with  this 
opinion.  In  no  instance  in  the  writer's  experience  has  a  sporadic  case 
of  rubella  been  observed,  nor  has  it  ever  been  limited  to  a  single  family, 
while  sporadic  cases  of  measles  and  scarlatina,  or  instances  of  infection 
limited  to  a  single  dwelling,  have  several  times  been  encountered. 
This,  however,  should  not  be  construed  to  mean  that  such  cases  never 
occur.  It  is  not  known  what  special  influences  determine  epidemics 
of  rubella,  further  than  that  they  occur,  for  the  most  part,  in  the  cool, 
damp  months.  From  the  fact  that  epidemics  frequently  appear  on  the 
Island  of  Malta  as  soon  as  the  rainy  season  sets  in,  Walch010  concluded 
that  the  virus  might  arise  spontaneously.  While  admitting  that  many 
epidemics  of  rubella  are  mistaken  for  mild  cases  of  measles,  the  writer 
is  of  opinion  that  they  occur  at  less  frequent  intervals  than  do  those  of 
either  scarlatina  or  measles.  During  the  past  year  an  epidemic  of  mea- 
sles occurred  in  Cleveland,  during  which  some  of  the  illustrations  for 
the  present  work  were  taken.  The  epidemic  began  in  March  with  a  few 
scattered  cases  and  in  April  and  May  was  at  its  height.  Early  in  May 

615  Keating:  "Trans.  Coll.  Phys.  Phila.,"  June  1,  1882. 

616  \valch,  quoted  by  Griffith  (loc.  cit.). 


364  THE    ACUTE    EXANTHEMATA. 

the  first  cases  of  rubella  were  seen.  These  increased  slowly  at  first,  but 
in  the  course  of  from  four  to  six  weeks  the  disease  multiplied  rapidly 
and  the  epidemic  reached  its  maximum;  while  the  epidemic  of  measles 
had  well-nigh  disappeared.  In  this  epidemic  the  contagium,  feeble  at 
first,  increased  in  virulence  by  successive  transmissions,  and  it  con- 
tinued until  hot  weather  set  in  about  the  last  of  June,  and  no  cases 
were  reported  after  the  middle  of  July.  From  this  it  would  appear  that 
the  virus  is  subject  to  cultivation,  and  varies  in  activity  at  different 
times  and  under  different  conditions.  This  would  account  for  the  wide 
discrepancy  of  authors  concerning  its  contagiousness. 

Its  contagious  property  has  long  since  been  known,  and  is  duly  in 
accord  with  common  observation.  For  instance,  in  an  institution  con- 
taining 100  children,  Griffith  reports  that  37  took  the  disease  in  spite 
of  prompt  and  careful  isolation.  Of  196  inmates  in  an  asylum,  accord- 
ing to  Hatfield,617  110  were  affected. 

On  the  other  hand,  most  authors  regard  it  as  less  contagious  than 
measles,  and  some  (von  Nymann,  Klaatsch)  speak  of  it  as  very  feebly 
contagious,  while  others  (Steiner,  Kassowitz)  have  even  doubted  its 
contagious  character.  So  far  as  the  present  writer  has  been  able  to 
ascertain,  it  is  at  certain  times  not  only  as  contagious  as  measles,  but 
the  contagium  retains  its  vitality  longer  after  being  cast  off,  and  in  this 
respect  it  corresponds  more  closely  to  that  of  scarlatina.  For  this 
reason  it  is  more  prone  to  adhere  to  clothing  or  to  be  carried  by 
fomites. 

Its  infectious  property  has  been  especially  emphasized  by  Edwards 
(loc.  cit.,  p.  687),  who  estimates  that  fully  75  per  cent,  of  cases  in  an  epi- 
demic in  Philadelphia  was  traced  to  infection  from  the  bunks  of  ships. 
This  would  tend  to  confirm  the  opinion  that  the  virus  is  more  tenacious 
of  life  than  is  usually  observed  in  measles.  It  is  also  supposed  that  it 
may  be  carried  by  a  third  person,  and  may  retain  its  infective  prop- 
erty for  some  time  about  rooms,  dwellings,  etc.  Little  is  known  as  to 
the  stage  in  which  the  disease  is  most  readily  communicated,  but,  like 
other  affections  of  its  class,  it  is  probably  contagious  as  soon  as  the  first 
symptoms  appear.  Squire618  believes  it  may  be  communicated  before 
the  rash  appears  and  for  a  month  thereafter,  and  Griffith  (loc.  cit.) 
found  that,  in  spite  of  prompt  segregation  as  soon  as  the  first  symp- 


817  Hatfleld:  Chicago  Medical  Examiner,  August,  1881. 

818  Squire  (William):   "Trans.  Internat.   Med.  Cong."   (London,  1881),  abstracted  in 
Archives  of  Derm.,  New  York,  July,  1882,  p.  221. 


RUBELLA.  305 

toms  appeared,  the  disease  continued  to  spread;  which  goes  to  prove 
that  it  is  contagious  as  soon  as  the  symptoms  become  manifest  and 
probably  during  the  prodromal  stage.  As  in  measles,  we  have  reason  to 
believe  that  the  contagium  is  contained  in  the  blood  and  possibly  the 
secretions  of  certain  mucous  membranes,  such  as  the  tears,  sputum,  and 
nasal  discharges  when  such  exist. 

Age  plays  an  unimportant  part  in  the  etiology  of  rubella.  As 
in  various  other  infectious  diseases  which  appear  at  frequent  intervals, 
many  children  are  attacked,  thus  rendering  them  immune  for  the 
rest  of  life;  many,  however,  escape,  which  renders  them  susceptible 
later  in  life.  I  have  been  impressed  by  the  number  of  cases  in  adults 
that  have  presented  themselves  at  my  clinic  at  Lakeside  Hospital, 
showing  that  the  number  of  susceptible  persons  in  adult  life  is  very 
considerable.  This  may  be  accounted  for  by  the  comparative  infre- 
quency  of  epidemics,  and  the  resistance  offered  by  many  to  infection. 
'Hardaway  (loc.  cit.,  p.  583)  has  observed  in  a  number  of  instances  that 
the  disease  when  introduced  into  families  attacked  only  one  or  two  of 
a  large  number  equally  exposed.  J.  Lewis  Smith  (loc.  cit.,  p.  305)  and 
Liveing619  have  likewise  observed  this  peculiarity.  My  experience  in 
regard  to  the  frequency  with  which  adults  are  attacked  with  rubella 
seems  to  be  uncommon.  Thomas  reports  only  3  adults  in  77  cases; 
of  42  cases  reported  by  Emminghaus,  2  were  in  adults;  19  to  1  is  the 
ratio  given  by  Both820;  in  64  cases  Kassowitz  (loc.  cit.)  noted  only  5 
adults;  and  of  Griffith's  100  cases,  only  1  was  in  an  adult.  Infants 
usually  escape,  partly  on  account  of  their  more  general  protection  from 
exposure,  partly  because  of  their  partial  immunity.  This,  however,  is 
not  without  many  exceptions,  and  infants  have  contracted  the  disease 
a  few  days  after  birth.  Hardaway  gives  from  five  to  fifteen  years  as 
the  time  of  life  in  which  the  disease  is  most  prevalent,  while  Edwards 
says  that  most  cases  occur  before  the  fifth  year.  Finally,  while  notes 
taken  by  the  present  writer  do  not  show  the  disease  later  than  the 
twenty-ninth  year,  it  may  occur  in  advanced  life,  as  shown  by  Seitz, 
who  reports  rubella  in  a  woman  aged  seventy-three  years  (Edwards). 
Thus,  age  alone  offers  no  sure  barrier  to  infection,  while  it  must  be 
conceded  from  the  foregoing  that  rubella  is  essentially  a  disease  of 
childhood. 

Sex  has  no  influence  on  the  disease. 


819  Liveing  (Robert) :  London  Lancet,  March  14,  1874. 
920  Roth,  quoted  by  Edwards  (loc.  cit.).     • 


366  THE   ACUTE    EXANTHEMATA. 

DIAGNOSIS. 

Measles. — As  may  be  seen  from  the  foregoing  pages,  rubella  is 
most  liable  to  be  confounded  with  measles,  and  while,  in  a  general 
way,  the  two  diseases  present  a  marked  dissimilarity,  yet  in  cases  which 
depart  from  the  usual  type,  when  isolated,  or  at  the  beginning  of  an 
epidemic,  it  is  generally  admitted  that  some  difficulty  in  differentiating 
the  two  would  be  encountered.  There  is  no  pathognomonic  or  unvary- 
ing guide  between  these  diseases,  and  the  diagnostician  must  rely  solely 
on  the  course  and  general  character  of  the  affection.  There  is  no  one 
symptom  that  may  not  be  counterfeited  in  the  other  disease,  so  that  it 
is  unsafe  to  rely  on  this  or  that  symptom  in  arriving  at  a  conclusion. 
Moreover,  it  has  been  shown  that  the  initial  period  in  rubella  may 
be  unduly  protracted,  and  that  of  measles  shortened;  that  the  coryza 
in  measles  may  be  insignificant,  while  it  may  be  pronounced  in  ru- 
bella; that  fever  may  precede  the  eruption  in  rubella  one  or  more  days, 
while  it  may  scarcely  be  detected  in  the  prodromal  stage  of  measles; 
that  in  measles  it  may  be  impossible  to  obtain  any  history  of  sickness 
preceding  the  rash,  while  in  rubella  pains  in  the  joints,  headache, 
nausea,  and  vomiting  may  be  pronounced;  and,  finally,  that  the  erup- 
tion may  be  faint  and  indistinct  in  measles,  while  bright  and  well 
pronounced  in  rubella. 

The  enlargement  of  the  superficial  lymphatic  glands  is  sometimes 
pronounced  in  measles,  while  it  may  be  imperceptible  in  rubella;  and 
in  many  cases  the  lesions  in  the  mouth  and  fauces  offer  no  signs  that 
are  sufficiently  peculiar  and  invariably  distinctive  in  each  disease  to  be 
termed  pathognomonic.  Taken  together,  however,  the  symptoms  are 
distinctive,  and  when  a  number  of  cases  occur,  as  in  an  epidemic,  the 
type,  as  detailed,  will  readily  become  apparent.  Added  to  this  the  fact 
that  the  disease  attacks  indiscriminately  those  who  have  and  those 
who  have  not  previously  had  measles,  the  diagnosis  may  be  arrived  at 
with  certainty.  Of  48  cases  reported  by  J.  Lewis  Smith,  19  had  pre- 
viously had  measles  and  1  patient  who  had  rotheln  took  measles  sub- 
sequently (loc.  cit.,  p.  303);  of  33  cases  reported  by  De  Man,021  10,  or 
nearly  one-third,  gave  a  previous  history  of  measles;  of  Thierfelder's 
45  cases,  22,  or  about  one-half,  had  had  measles;  of  Shuttleworth's022 
27  cases,  15  are  reported  to  have  had  measles;  and  of  88  cases  reported 


m  De  Man,  quoted  by  Griffith  (loc.  cit.). 

•»  Shuttleworth :  Brit.  Med.  Jour.,  1880,  ii,  p.  49. 


RUBELLA.  367 

by  Dukes,623  fully  61  had  had  rubeola.  The  fact  that  any  individual 
patient  has  had  measles  should  not,  however,  be  taken  as  proof  posi- 
tive that  the  present  attack  must  necessarily  be  rubella,  for  numerous 
well  authenticated  instances  are  recorded  in  which  measles  has  oc- 
curred a  second  time.  In  an  epidemic  of  rubella  it  must  soon  appear 
to  the  most  indifferent  or  careless  observer  that  prodromal  symptoms 
are  absent,  or  nearly  so,  in  all  cases;  that  coryza,  lacrymation,  and 
photophobia  are  not  troublesome;  that  there  is  little  or  no  fever 
throughout  the  whole  course  of  the  disease;  that  the  eruption  is  light 
colored  instead  of  dusky  and  cyanotic,  and  enlargement  of  the  post- 
cervical  lymphatic  gland  is  well-nigh  constant  and  out  of  propor- 
tion to  the  mild  character  of  the  affection.  The  fleeting  character  of 
the  eruption  is  more  pronounced  than  in  measles,  and  on  this  account 
a  typical  illustration,  showing  the  mature  eruption  over  the  whole 
body  as  in  measles,  could  not  be  procured.  (See  Plate  XLI.)  While 
it  may  be  impossible  to  differentiate  in  some  cases  from  the  eruption 
alone,  yet  it  serves  a  useful  purpose  in  the  ensemble.  In  this,  the  color 
is  important,  and  when  simulated,  as  it  often  is  in  mild  cases  of  mea- 
sles, the  remaining  symptoms  do  not  correspond  to  the  same  degree. 
For  example,  a  mild  attack  of  measles  with  a  pinkish  exanthem  usually 
shows  a  marked  disturbance  of  the  various  mucosaB.  Again,  the  size 
and  contour  of  the  lesions  should  be  noted,  as  they  rarely  fail  to  afford 
some  assistance  in  the  diagnosis.  The  spots  in  rubella  are  always 
smaller  than  in  measles,  and,  when  they  do  coalesce  to  form  larger 
plaques  or  extensive  areas,  the  margins  and  outlying  regions  retain  the 
small,  roundish,  ill-defined  macules. 

Finally,  the  following  distinctive  points  should  be  kept  in  mind: — 

First. — That  rubella  is  sometimes  feebly  contagious,  while  mea- 
sles is  always  violently  contagious. 

Second. — The  prodromal  stage  is  always  short  and  quite  insig- 
nificant in  rubella,  while  in  measles  it  continues  from  three  to  four 
days. 

Third. — In  measles  the  prodromal  stage  is  usually  accompanied 
by  marked  constitutional  symptoms,  with  catarrh  of  the  upper  air- 
passages,  lacrymation,  photophobia,  and  a  more  or  less  characteristic 
eruption  in  the  mouth,  which  appears  from  twelve  to  forty-eight  hours 
before  the  cutaneous  exanthem.  In  rubella  no  characteristic  pro- 


823  Dukes  (Clement):  "On  the  Features  which  Distinguish  Epidemic  Roseola  (Rose- 
rash)  from  Measles  and  from  Scarlet  Fever"  (London,  1894),  and  London  Lancet,  1881,  ii, 
p.  743.  . 


368  THE   ACUTE    EXANTHEMATA. 

dromata  are  observed,  and  only  at  the  beginning  of  the  eruptive  stage 
is  there  usually  a  slight  hyperaemia  of  the  conjunctiva?,  of  the  faucial 
mucous  membrane,  and  rarely  of  the  upper  air-passages.  On  the  soft 
palate  and  uvula  there  is  sometimes  a  punctate  or  faint  macular  enan- 
them,  which  by  some  is  considered  distinctive.  Even  in  mild  cases  of 
measles  the  disturbance  of  the  mucous  membranes  is  more  severe  than 
in  severe  cases  of  rubella,  and  there  is  always,  so  far  as  I  have  observed, 
a  bluish  or  skim-milk  tint  to  the  mucous  membrane  of  the  mouth, 
which  I  have  never  found  in  rubella.  In  rubella  sore  throat  is  present 
in  nearly  all  cases,  while  in  measles  sore  throat  is  uncommon. 

Fourth. — The  eruption  in  rubella  appears  most  frequently  on  the 
first  or  second  day,  rarely  later.  It  often  disappears  from  parts  first 
attacked  before  other  regions  become  involved.  It  is  of  a  pale-red  or 
pinkish  color,  very  rarely  assuming  a  dusky  tint,  and  the  individual 
spots  are  surrounded  by  a  faint  areola,  thus  obscuring  the  outline  of 
the  lesion.  The  spots  are  papulo-macular,  for  the  most  part  round  or 
slightly  oval  in  shape,  and  present  no  tendency  to  form  crescents  or 
groupings.  Sometimes  by  coalescing  they  unite  to  form  extensive 
areas,  which,  in  all  cases  either  at  the  periphery  or  on  more  remote 
parts,  are  associated  with  the  discrete,  small  macules  which  give  char- 
acter to  the  eruption.  The  rash  rarely  lasts  longer  than  three  day.-, 
and  most  frequently  it  disappears  on  the  upper  part  of  the  body  on  the 
second;  while  in  measles  the  eruption  almost  always  appears  on  the 
morning  of  the  fourth  day,  sometimes  on  the  third,  and  rarely  earlier. 
In  measles  the  color  is  of  a  dark  or  purplish  red,  and  the  lesions  are 
well  defined,  with  normal  skin  intervening.  They  enlarge  at  the 
periphery  and  show  a  marked  tendency  to  form  groups  and  crescents. 
These  are  especially  marked  on  the  face,  neck,  and  upper  part  of  the 
trunk.  In  all  cases  the  individual  lesions  are  larger  than  in  rubella  and 
present  an  irregular  or  serrated  margin.  The  eruption  attains  its  max- 
imum development  more  slowly  than  in  rubella;  so  that  the  whole 
surface  of  the  body  may  be  involved  at  the  same  time,  consequently, 
it  remains  longer  than  that  of  rubella,  lasting  from  four  to  five  days  or 
longer,  when  defervescence  begins. 

Fifth. — In  rubella  the  superficial  lymphatic  glands  of  the  neck  are 
nearly  always  involved,  being  swollen  and  sometimes  painful;  while  in 
measles  marked  or  painful  enlargement  of  the  glands  of  the  neck  is 
decidedly  uncommon. 

Sixth. — In  rubella  the  temperature  may  be  only  slightly  above 
the  normal  at  any  time  during  the  course  of  the  disease,  and  it  rarely 


RUBELLA.  369 

/ 

exceeds  102°  F.  (38.8°  C.).  NOT  is  the  temperature  curve  in  any 
way  characteristic  of  the  affection.  Further,  it  is  usually  of  short  dura- 
tion and  rarely  continues  beyond  the  second  or  third  day.  In  measles 
fever  is  always  present  and  the  temperature  is  sometimes  high.  There 
is  an  initial  rise  of  temperature  during  the  prodromal  stage,  which 
usually  subsides,  returning  just  previous  to  the  appearance  of  the 
eruption,  and  attaining  its  maximum  at  the  height  of  the  efflorescence. 
The  fever  may  continue  until  the  seventh  or  eighth  day. 

Seventh. — Rubella  is  seldom  accompanied  by  complications  or  fol- 
lowed by  sequelae,  while  in  measles  complications  are  common  and  con- 
stitute the  most  serious  feature  of  the  disease. 

Scarlet  Fever. — Next  to  measles,  rubella  is  most  usually  mistaken 
for  mild  cases  of  anomalous  scarlatina.  This  occurs,  however,  only 
when  the  sore  throat  in  rubella  is  unusually  severe,  the  fever  high,  and 
the  rash  punctate  and  confluent.  It  is,  indeed,  seldom  that  all  of  these 
occur  in  rubella  at  the  same  time;  hence,  only  in  very  exceptional 
cases  is  there  danger  of  confounding  the  two  diseases.  There  is  a 
striking  contrast  between  the  onset  of  these  affections.  In  rubella  it 
is  mild  and  insidious,  while  in  scarlatina  it  is  ushered  in  by  short  though 
violent  prodromata,  fever,  and  sometimes  vomiting.  The  appearance 
of  the  throat  in  some  cases,  and  usually  the  tongue,  may  be  considered 
almost  pathognomonic  in  scarlatina,  while  these  symptoms  are  ill  de- 
fined or  wholly  absent  in  rubella. 

The  eruption  is  fiery  red,  appearing  first  on  the  neck  or  upper 
part  of  the  trunk  in  scarlatina,  and  on  the  face  in  rubella.  In  the  latter 
disease  it  is  evanescent,  while  in  the  first  named  it  continues  from  five 
to  seven  days.  In  scarlatina  the  rash  is  made  up  of  minute,  brightly 
injected  puncta,  slightly  elevated  and  closely  studded  together,  form- 
ing a  uniform  or  finely  mottled  surface,  while  the  rash  of  rubella  is 
always  "measly,"  and  never  becomes  entirely  confluent.  In  rubella  the 
rash  invades  the  region  of  the  lips,  while  the  skin  about  the  mouth  is 
comparatively  free  in  scarlatina.  Finally,  scarlatina  is  not  infrequently 
accompanied  by  grave  constitutional  symptoms,  such  as  pharyngo-nasal 
inflammation,  otitis,  etc.,  together  with  albuminuria  and  casts,  which 
are  almost  unknown  in  rubella.  Withal,  scarlatina  is  one  of  the  most 
virulent  diseases  of  childhood,  while  rubella  is  one  of  the  mildest, 
shortest,  and  most  benign. 

Syphilis. — In  my.  clinic  it  has  been  observed  that  most  cases  of 
rubella  present  a  somewhat  feeble  resemblance  to  the  early  efflores- 
cence of  syphilis,  and  nearly  all  are  classed  by  the  distributing  clerk 


370  THE   ACUTE    EXANTHEMATA. 

under  this  disease.  The  mild  though  wide-spread  catarrhal  disturb- 
ance, however,  instead  of  the  more  limited  faucial  congestion  of  syph- 
ilis, together  with  the  color  and  distribution  of  the  exanthem,  are 
usually  sufficient  to  enable  one  to  readily  differentiate  between  them. 
The  presence  or  absence  of  the  initial  lesion  of  syphilis  would  naturally 
afford  valuable  information  for  diagnostic  purposes. 

Drug  eruptions  might  possibly  in  some  instances  be  mistaken  for 
rubella,  but  what  has  previously  been  said  under  measles  applies 
equally  to  rubella. 

PROGNOSIS. 

The  prognosis  of  rubella  is  favorable,  although  it  must  be  con- 
ceded that  it  varies  somewhat  in  different  epidemics,  and  is  further 
influenced  by  the  previous  health  and  sanitary  surroundings  of  the 
patient.  In  the  epidemic  reported  by  Edwards,  in  which  small  chil- 
dren were  admitted  to  the  hospital  from  the  steerage  of  ships,  and  after 
the  consequent  hardships  of  a  long  ocean  voyage,  it  is  not  strange  that 
the  disease  assumed  such  grave  complications,  and  was  followed  by 
the  almost  unprecedented  death-rate  of  4  1/4  per  cent.  Hatfield,  how- 
ever, records  a  mortality  of  9  per  cent.,  under  possibly  worse  sanitary 
conditions,  while  Aitken,  Patterson,  and  Copeland,  according  to  Ed- 
wards, say  that  the  prognosis  should  be  guarded.  Klaatsch  quotes 
Kronenberg  to  the  effect  that  bronchitis,  pneumonia,  and  cerebral  con- 
gestion caused  four  deaths  in  the  cases  under  his  care.  On  the  other 
hand,  there  is  a  consensus  of  opinion  among  writers  as  to  the  benign 
course  and  favorable  termination  of  the  disease.  As  has  been  pointed 
out  iinder  the  head  of  complications,  the  strong  tendency  to  or  the 
occurrence  of  many  diseases  may  be  facilitated  by  an  attack  of  rubella 
in  the  same  way  that  a  common  coryza  may  be  the  precursor  of  phthi- 
sis. Under  ordinary  conditions,  however,  the  prognosis  may  be  con- 
sidered almost  invariably  favorable. 

TREATMENT. 

It  is  not  usually  considered  necessary  to  institute  very  rigid  quar- 
antine measures  in  rubella,  although  delicate  children  should  not  be 
ruthlessly  exposed.  In  asylums  and  other  unfavorable  institutions  the 
same  rules  apply  that  were  given  under  the  prevention  of  measles. 
Von  Jiirgensen  advises  that  children  be  kept  from  school  for  about 
five  weeks,  and  that  the  same  precautions  be  taken  that  are  recem- 


KUBELLA.  371 

mended  for  measles.     This,  in  my  opinion,  is  uncalled  for,  as  the 
duration  of  the  disease  is  short  and  its  contagium  easily  destroyed. 

In  patients  of  average  health  no  treatment  whatever  is  required, 
except  to  guard  against  undue  exposure  to  cold  and  wet.  It  is  advis- 
able to  retain  patients  having  ruhella  within  doors,  although  it  is  not 
necessary,  unless  catarrhal  or  other  complications  arise,  to  confine  them 
to  bed.  The  diet  should  be  regulated  according  to  their  condition,  and 
usually  a  mild,  easily  digestible  dietary  is  to  be  preferred.  If  compli- 
cations arise,  they  should  be  treated  according  to  the  general  principles 
applicable  to  the  affection  without  special  reference  to  the  exanthem. 
After  recovery  the  apartments  should  be  fumigated  and  freely  aired. 


ADDENDUM. 


374 


THE    ACUTE    EXANTHEMATA. 


TABLE  SHOWING  THE  CHIEF  FEATURES  IN 

INFECTIOUS 


VARIOLA. 

VARICELLA. 

Twelve  days. 

Fourteen  days. 

Always   present  and   usually  severe. 

Often  not  observed  at  all  and  never 

PRODROMAL  SYMPTOMS. 


with  headache,  vomiting,  pain  in 
the  back,  and  high  fever;  dura- 
tion, three  days. 


TIME   THE    ERUPTION    AP- 
PEAKS  ON  THK  SKIN. 


Appears  fairljr  constantly  on  morning 
of  fourth  day  ;  first  seen  on  fore- 
head and  face. 


severe,  consisting  of  the  ordinary 
mild  febrile  symptoms,  which 
seldom  continue  longer  than  from 
a  few  hours  to  n  day. 


Often  the  first  symptom  noticed:  usu- 
ally first  appearance  on  back  and 
chest. 


APPEARANCE  AND  DEVELOP- 
MENT or  THE  ERUPTION. 


First  red  and  papular,  feeling  like  shot 
imbedded  in  the  skin :  appears  in 
regulur  order  from  above  down- 
ward and  entire  body  involved  in 
from  twenty-four  to  thirty-six 
hours:  on  second  or  third  day 
vesicles  form  on  papules  having 
thick  walls,  which  become  opales- 
cent within  a  day  or  two  and  fi- 


Kirst  macular  and  deep  pink,  with 
formation  of  vesicle  in  centre 
within  a  few  hours ;  develops  rap- 
idly to  size  of  split  pea  and  is 
translucent,  with  thin  wall:; :  fully 
developed  on  second  day :  appears 


nally  yellow;    umbilication   at 
some  period  of  development,  ma- 
ture on  eighth   day  of  eruption, 
sooner  in  varioloid:   contents  not 
readily  evacuated. 

in  crops  without  order  on  different 
parts  of  the  body  ;    never  indu- 
rated and  easily  evacuated. 

ERUPTION  ON  Mucous 
MEMBRANES. 

Throat  often  reddish  ;  pustules  often 
seen  on  tongue,  pharynx,  and  in- 
ner surface  of  cheeks,  co-existent 
with  exanthem  ;    lips  and  tongue 
parched  and  dry. 

Tongue  often  slightly  coated  :   vesicu- 
lar enanthem   often    appears    on 
palate  and  inner  surface  of  cheeks 
simultaneously  with  eruption  on 
skin:   usually  appears  as   small, 
excoriated  spots. 

CONSTITUTIONAL  SYMPTOMS. 

Often  severe,  but  depend  on  extent  of 
the  eruption:    mild  in  varioloid; 
often   disappear  on  appearance  of 
rash. 

Slight  and  usually  absent. 

FEVER. 

Temperature  falls  on  appearance  of 
rash  and  usually  rise.'  when  pust- 
ules mature  about  the  eighth  dny  ; 
morning  remissions  common. 

Always    slight:    sometimes    detected 
only  when  eruption  appears  and 
sometimes  not  at  all. 

Desiccate,  forming  superficial  crusts  ; 

Pocks  desiccate  and  form  dark  crusts  ; 

DESQUAMATIOX.  usually  complete  in  from  fifteen 

to  twenty-four  days,  leaving  scars. 


fall  off  in  from  seven  to  fifteen 
days,  often  leaving  pigmentation 
and  sometimes  superficial  scars 


COMPLICATIONS  AXD 
SEQUELS. 


Furuncles,  abscesses,  and  tuberculosis. 


ADDEND  I'M. 


375 


THE  DIFFERENTIAL  DIAGNOSIS  OF  THK  ACUTE 
EXANTHEMATA. 


Kleven  days. 


Fourteen  to  eighteen  days. 


Coryza,  dry  cough,  and  watering  of         Often  absent,  always  mild  :  slight 


SCARLATINA. 


Two  to  five  days. 


the  eyes,  with  photophobia. 
moderate  fever,  sometimes  vom- 
iting; usually  continues  three 
davs. 


Morning  of  fourth  day,  on  face  or 
iiuck. 


Macnlar,  blotchy,  dark  red  or 
slightly  violaceous:  size  of  large 
bean:  tends  to  form  clusters: 
lesions  serrated  at  margin  and 
slightly  elevated ;  disappear  in 
three  or  four  days. 


sore  throat,  watering  of  the 
eyes,  and  swelling  of  post- 
cervical  lymph-glands :  one 
or  two  days'  duration. 


Usually  first  or  second   day.  on 
face  or  upper  part  of  trunk. 


Small,  faded  rose-colored  spots: 
discrete, not  in  clusters:  may 
resemble  either  measles  or 
scarlatina:  appear  in  regular 
order  on  the  face,  trunk,  up- 
per and  lower  extremities: 
fade  on  face  befnre  legs  in- 
volved :  disappear  in  two  or 
three  days. 


Headache,  sore  throat,  high  fever, 
rapid  [ulse;  may  have  vom- 
iting and  severe  nervous 
symptoms:  submaxillKry 
glands  usually  enlarged  and 
tender  to  touch  :  duration, 
twenty-four  hours  or  less. 


During  first  or  second  day.     On 
neck  and  upper  part  of  chest. 


Punctate,  intensely  red,  confluent 
and  apparently  continuous: 
"boiled  lobster"  appearance. 
It  travels  downward,  invad- 
ing whole  body  in  from  twelve 
to  twenty-four  hmirs  :  avoids 
region  of  mouth  and  nose; 
remains  three  or  four  da  vs. 


Bluish,  or    "skimmed-milk,"   tint 
often  seen  the  first  day  :  charac- 
teristic   enanthem    often    seen 
twenty-four  to  forty  -eight  hours 
before  skin  eruption  ;   consists 
of   reddish   maculae,  with  cen- 
tral b  uish-white  dots,  best  seen 
on    hard    and    soft    palate   and 
inner  surface  of  cheeks. 

Slight  macular.  enanthem  comes 
at  first  appearance  of  exan- 
them  and  is  best  seen  on  soft 
palate. 

Early  on  second  day  diffuse  mot- 
tled    reddening     first     over 
uvula,  hard  and  soft  palate, 
and  inner  surface  of  cheeks  : 
"  strawberry  tongue"  :  throat 
continues    red    and   tonsils 
swollen. 

Increase  with  eruption. 

Very  mild  or  absent. 

'  All  symptoms  increase  with  de- 
velopment of  eruption  ;  pulse 
rapid  and  out  of  proportion  to 
fever. 

Increases  with  development  of  rash 
and     subsides    when     eruption 
matures. 

Very  little,  if  any. 

Continues  high  for  from  three  to 
six  days. 

Hraiiny.  begins  on  fourth  day,  and 
is  usually  imperceptible. 

Scarcely  perceptible. 

Begins  on  sixth  to  eighth  day; 
sometimes  in  large  flakes. 

Frequent  :   broncho-pneumonia,  tu- 
berculosis, snppnrative  inflam- 
mation of  middle  ear,  and  naso- 
pharyngeal  catarrh. 

Nose. 

Albuminuria    is    almost  always 
present,  and  renal  complica- 
tions are  frequent. 

376  THE   ACUTE    EXANTHEMATA. 

FORMULARY  FOR  DISINFECTION  ESPECIALLY  APPLI- 
CABLE TO  THE  EXANTHEMATA. 


&  Menthol!     gr.  iij     (     0.2000) . 

Thymoli gr.  V10   (     0.0065). 

Ol.  gaultheriae    mij          (     0.0300) . 

Glycerin!    f3iv         (   16.0000). 

Chlorophyll    (sol.   aquae) q.  s. 

Aquae     q.  s.  ad  fjviij      (240.0000) . 

M.  Sig. :  May  be  used  when  a  mild  disinfectant  is  desirable,  as  a  gargle 
to  the  mouth  and  throat,  or  diluted  in  the  form  of  a  spray  into  the  nares, 
larynx,  etc. 

The  vegetable  green  is  used  only  to  give  it  a  distinctive  color,  as 
it  is  advisable  to  have  all  poisonous  and  non-poisonous  solutions  used 
in  the  sick-chamber  or  hospital  ward  readily  distinguishable.  Thus, 
all  gargles,  sprays,  and  innocuous  solutions  may  be  TINTED  GREEN; 
external  applications  of  a  mild  nature  YELLOW  or  WHITE;  and  all 
caustic  and  poisonous  solutions  RED  or  PURPLE.  Either  the  tincture 
of  cudbear  or  the  potassium  permanganate  will  serve  well  as  coloring 
agents  to  the  dangerous  class. 

No.  2.  ft  Tinct.  saponis  viridis fgij    (  60.0). 

Glycerini     f3ij    (     7.0). 

Formaldehydi    f3j     (     3.5). 

Aquae     q.  s.  ad  f&v   (120.0). 

M.  Sig.:  Hospital  soap.  This  cleanses  more  effectually  than  hard  soap, 
and,  as  it  does  not  usually  injure  the  epidermis,  may  be  used  by  delicate- 
skinned  persons. 

Xo.  3.   ft  Hydrarg.  bichloridi gr.  iv  (     0.26). 

Glycerini     f3vj  (  21.00) . 

Ol.  myricee gtt.  x  (     0.60) . 

Essen,  lavandulae   f3iv  (   14.00). 

Aquae     q.  s.  ad  fj$xvj  (480.00). 

M.     Sig.:    To  be  used  as  a  toilet  lotion. 

If  this  prove  too  irritating  the  following  may  be  substituted: — 

No.  4.  ft  Tinct.  sapon.  viridis f3ij  (     7.0). 

Tr.  benzoinse f3ij  (     7.0) . 

Alcoholis    f3ij  (     7.0). 

Formaldehydi  mlxxx  (     4.7 ). 

Glycerini    f3iv  (   14.0) . 

Aquae  dest q.  s.  ad  fjxvj  (480.0). 

M.  Sig.:  To  be  used  as  a  toilet  lotion  for  the  hands,  etc.  It  may  also 
be  employed  as  a  substitute  for  soap. 


ADDENDUM.  377 

No.  5.  ft  Acidi  borici  $i-iij    (  40.0) . 

Essen,  lavandulse  f3v       (  20.0) . 

Alcoholis    q.  s.  ad  f^xvj    (480.0). 

M.  Sig. :  To  be  applied  as  a  lotion.  Especially  applicable  to  the  face  or 
general  surface  of  the  body  in  variola,  measles,  scarlatina,  varicella,  etc. 

No.  6.  ft  Calc.   chlorinatae    $xvj     (  453.6). 

Aquae    C.  iij   (2880.0). 

M.  Sig.:  To  be  employed  as  a  general  disinfectant,  used  freely  in  privy- 
vaults,  sewers,  sink-drains,  refuse  heaps,  stables,  and  elsewhere,  provided  the 
odor  is  not  objectionable.  It  is  one  of  the  cheapest  and  most  effective  disin- 
fectants and  germicides  available  for  general  use.  It  must  be  used  freely,  how- 
ever, and  should  come  in  direct  contact  by  wetting  everything  required  to  be 
disinfected.  It  should  be  remembered  that  its  odor  does  not  disinfect,  but  only 
neutralizes  or  covers  up  other  odors. 

This  solution,  being  inexpensive,  may  be  used  with  great  freedom. 
A  quart  or  more  may  be  used  each  day  in  an  offensive  vault,  and  in 
proportionate  quantities  in  other  places.  In  the  sick-room  it  may  be 
used,  when  its  odor  does  not  prove  offensive,  in  vessels,  cuspidors,  etc. 
Sheets  and  other  clothing  used  by  the  patient  may  be  immersed  in  a 
pail  or  tub  of  this  solution,  diluted  (1  gallon  of  the  solution  to  10  of 
water)  for  two  hours,  or  until  ready  for  the  wash-room  or  laundry.  It 
is  not  poisonous  nor  does  it  injure  white  clothing. 

It  may  also  be  used  for  washing  the  hands  or  other  parts  of  the 
body  when  exposed  to  infection  from  excreta,  etc.  When  used  on  the 
hands  it  is  advisable  to  anoint  the  skin  immediately  afterward  with 
vaselin,  or,  better,  Formula  No.  10,  to  prevent  undue  irritation  and 
chapping.  In  preparing  it  care  should  be  taken  to  obtain  fresh  chloride 
of  lime. 

An  odorless  substitute  for  the  above  may  be  prepared  by  sprink- 
ling 1  quart  (960  cubic  centimetres)  of  water  gradually  upon  a  quart  of 
quick-lime  broken  in  small  pieces  in  a  metallic  or  wooden  vessel.  When 
the  lime  is  reduced  to  a  powder  3  quarts  (2880  cubic  centimetres)  of 
water  should  be  added  and  the  whole  kept  in  a  covered  vessel  and 
labeled  milk  of  lime. 

No.  7.  ft  Hydrarg.  bichloridi, 

Pot.  permanganatis   aa  gj  (     30.0) . 

Aquas    C.  viij   (7680.0). 

M.  Sig.:  Use  as  a  general  disinfectant.  It  is  poisonous,  but  its  bright- 
purple  color  will  prevent  its  being  mistaken  for  any  other  solution.  It  cor- 
rodes metallic  substances;  otherwise  it  may  be  used  in  the  same  way  and  for 
the  same  purposes  as  No.  6.  It  has  no  odor;  hence  its  use  is  more  agreeable 
in  vessels,  cuspidors,  and  in  the  sick-chamber,  while  the  chloride  of  lime  is 
better  for  vaults,  sewers,  drains,  etc. 


378  THE   ACUTE    EXANTHEMATA. 

No.  8.   U  Hydrarg.  bichloridi   3j       (     4.0) . 

Aqua;     . .  .C.  j    (960.0). 

M.  Sig. :  May  be  used  after  a  case  of  infectious  or  contagious  disease,  to 
wash  the  floor,  bedstead,  chairs,  and  other  furniture. 

The  walls  and  ceiling,  if  plastered,  may  be  whitewashed  with  lime 
containing  the  same  proportion  of  corrosive  sublimate  as  the  preced- 
ing, or  they  may  be  brushed  over  with  the  aqueous  solution.  Special 
care  must  be  taken  to  wash  all  the  dust  from  window-ledges,  corners, 
and  other  places  where  it  may  have  settled,  and  to  thoroughly  cleanse 
crevices  and  out-of-the-way  places.  After  the  application  of  the  dis- 
infecting solution,  the  windows  and  doors  should  be  widely  opened  for 
twenty-four  hours  or  longer  to  insure  free  ventilation,  after  which  the 
floors  and  wood-work  should  be  well  scrubbed  with  soap  and  water. 
This  should  be  followed  by  a  second,  more  prolonged  exposure  to  fresh 
air,  admitted  through  open  doors  and  windows. 

A  solution  of  carbolic  acid  (1  part  of  the  pure  acid  to  20  parts  of 
water)  may  be  employed  in  place  of  the  bichloride  solution.  This  is 
also  a  good  general  disinfectant  for  use  in  the  sick-room  when  its  odor 
is  not  objectionable. 

No.  9.  B  Zinci  sulphat 5iv     (     120.0). 

Sod.  chloridi    Jij      (       60.0). 

Aquae C.  j    (11520.0). 

M.    Sig.:    To  be  used  as  a  disinfectant  lotion  for  clothing,  dead  bodies,  etc. 

No.  10.  I*  Ol.  olives  f3ij   (     8.0). 

Lanolini, 

Vaselini aa  q.  s.  ad  Sij     (120.0) . 

M.  Sig.:  Used  to  protect  the  hands,  to  soften  the  skin  after  disinfection, 
as  an  unguent,  or  as  a  vehicle  for  antiseptic  substances  such  as  boric  acid, 
mercury,  etc. 

DISINFECTION  OF  THE  PERSON. 

The  surface  of  the  body  of  a  sick  person,  or  of  his  attendants, 
when  soiled  with  infectious  discharges,  should  at  once  be  cleansed  with 
a  suitable  disinfectant  agent.  For  this  purpose  either  No.  3  or  6  may 
be  used.  In  diseases  like  small-pox  and  scarlet  fever,  in  which  the  in- 
fectious agent  is  given  off  from  the  entire  surface  of  the  body,  occa- 
sional ablutions  with  the  former,  or  the  latter  solution,  diluted  with 
10  parts  of  water,  will  be  more  suitable  than  carbolic  acid  or  formalde- 
hyde, although  the  scalp  and  beard  of  attendants  and  physicians  should 
be  sprayed  with  a  2-  to  5-per-cent.  solution  of  the  last  named  drug. 


ADDENDUM.  37!) 

This  must  be  done  in  the  open  air,  care  being  taken  that  the  eyes  are 
protected. 

In  all  infectious  diseases  after  death  the  surface  of  the  body  should 
be  thoroughly  washed  with  one  of  the  solutions  above  recommended 
(preferably  Xo.  8  or  9),  and  then  enveloped  in  a  sheet  saturated  with 
the  same,  and  immediately  placed  in  a  metallic  or  air-tight  casket.  In- 
terment should  take  place  as  soon  as  possible. 

DISINFECTION  OF  CLOTHING. 

Of  the  greatest  importance  in  coming  in  contact  with  infectious 
diseases  is  the  proper  disinfection  of  the  clothing.  This  has  been 
treated  of  at  length  under  variola,  but  it  should  not  be  neglected  in 
less  virulent  affections.  Medical  men  should  ever  be  on  guard  against 
being  the  carriers  of  disease.  The  formaldehyde  spray  (5  to  15  per 
cent.)  is  the  best  disinfectant  for  this  purpose,  and,  when  this  is  supple- 
mented by  an  hour  or  two  in  the  open  air,  no  danger  need  be  feared. 
For  the  ward  or  sick-room  it  should  be  remembered  that  boiling  for 
half  an  hour  will  destro}^  the  vitality  of  all  known  disease-germs.  As 
a  general  disinfectant  for  all  washable  fabrics  there  is  no  better  method 
than  the  ordinary  laundry  affords.  Care  should  be  taken,  however, 
that  articles  thus  treated  are  sufficiently  boiled,  and  that  no  delay  or 
exposure  is  allowed  between  the  time  of  removal  from  the  person  or 
bed  of  the  patient  and  their  immersion  in  boiling  water,  or  the  dilute 
solution  given  under  Xos.  6  and  9.  To  obviate  all  danger  it  is  highly 
desirable  in  all,  and  in  some  cases  imperative,  that  clothing  be  not  per- 
mitted to  leave  the  infected  room  until  so  treated.  In  hospitals  soiled 
clothing  may  be  collected  in  rubber  bags  which  are  tied  tightly  and 
sprayed  with  formaldehyde  before  leaving  the  room.  This  method, 
however,  cannot  be  recommended  for  general  use. 

FUMIGATION. 

Three  methods  of  room  or  ward  disinfection  have  been  recom- 
mended in  the  text:  fumigation  by  sulphur-dioxide  gas,  by  formalde- 
hyde-gas, and  by  heat  in  the  form  of  steam.  Each  is  efficient  when 
properly  done.  The  destructive  effect  of  burning  sulphur- fumes  on 
most  contagia  has  long  since  been  known  and  sufficiently  confirmed 
by  general  observation.  Certain  precautions  are  necessary,  however, 
and  the  ordinary  method,  employed  by  the  author  for  many  years, 
may  be  given  as  follows: — 


380  THE   ACUTE    EXANTHEMATA. 

Fumigation  with  Sulphur. — The  infected  room  or  dwelling  must 
be  vacated,  and  all  articles  that  cannot  be  treated  by  the  solutions 
mentioned  should  be  exposed  as  freely  as  possible  to  the  sulphur- 
fumes.  Boxes  should  be  opened,  all  pockets  turned  inside  out,  and 
all  surfaces  exposed  both  inside  and  out.  Thus,  heavy  woolen  cloth- 
ing, silks,  furs,  stuffed  bed-covers,  pillows,  and  mattresses  should  be 
hung  in  the  room  during  disinfection.  In  case  of  small-pox,  or  when 
discharges  have  penetrated  upholstering,  bed-ticks,  pillows,  etc.,  they 
should  be  ripped  open  and  their  contents  spread  out  so  as  to  be  acted 
on  by  the  sulphur-fumes.  The  room  or  dwelling  should  then  be  closed 
as  tightly  as  possible,  but  cracks  and  corners  should  be  fully  exposed 
to  the  action  of  the  disinfectant.  Three  pounds  of  sulphur  (brimstone 
sticks  or  flower  of  sulphur  preferred)  to  a  room  ten  feet  square  (1360.77 
grammes — 305  centimetres).  It  is  placed  on  an  iron  pan  or  broad 
shovel,  which  is  supported  upon  bricks,  and  set  on  fire  by  live  coals 
or  with  the  aid  of  a  tablespoonful  of  alcohol  is  lighted  by  a  match. 
To  obviate  the  danger  of  fire,  the  iron  pot  or  pan  in  which  the  sulphur 
is  burned  should  be  placed  over  water  in  a  tub  or  pan.  Care  should 
be  taken  not  to  inhale  the  fumes,  and,  as  soon  as  it  begins  to  burn 
well,  to  leave  the  room  and  close  the  door.  It  should  be  seen  to  that 
all  the  sulphur  is  consumed,  and  that  the  room  is  kept  closed  for  sev- 
eral hours — from  three  to  six — according  to  the  virus  to  be  acted  upon. 
After  this  it  should  be  opened  as  freely  as  possible  and  currents  of  air 
and  sunlight  allowed  free  access  for  a  whole  day.  All  articles  in  the 
room  should  then  be  hung  in  the  open  air,  beaten,  and  shaken.  Car- 
pets are  best  fumigated  on  the  floor,  but  should  afterward  be  removed 
to  the  open  air  and  thoroughly  beaten.  In  no  case  of  dangerous  dis- 
ease should  this  disinfection  of  the  room,  clothing,  bedding,  etc.,  be 
omitted. 

Disinfection  by  Formaldehyde. — Formaldehyde  is  now  generally 
considered  to  be  superior  in  every  respect  to  sulphur  for  the  disinfec- 
tion of  rooms  and  their  contents,  if  used  with  care  and  exactness.  Our 
extensive  use  of  formaldehyde  as  a  disinfectant  during  the  past  three 
years,  both  at  the  Cleveland  Small-pox  Hospital  and  at  Lakeside  Hos- 
pital, has  demonstrated  its  value  as  a  surface  disinfectant  and  its 
superiority  in  many  ways  over  the  older  methods.  The  main  objection 
to  its  employment  arises  from  the  fact  that  it  is  only  a  surface  disin- 
fectant. To  overcome  this  objection  the  following  method,  employed 
at  Lakeside  Hospital,  may  be  recommended:  An  air-tight  chamber  of 
sufficient  dimensions  is  provided  with  an  exhaust  apparatus  so  that  a 


ADDENDUM.  381 

partial  vacuum  (eight  atmospheres  or  eight  pounds  to  the  square  inch) 
may  be  obtained.  Clothing,  mattresses,  pillows,  blankets,  etc.,  are 
placed  in  this  chamber,  the  air  exhausted,  and  formaldehyde  (5  ounces 
of  the  40-per-cent.  solution  to  every  1000  cubic  feet  of  space)  is  intro- 
duced. This  is  continued  for  four  or  more  hours.  At  the  Lakeside 
Hospital  it  is  customary  to  allow  articles  to  remain  in  the  disinfecting 
chamber  twenty-four  hours.  (In  the  absence  of  special  apparatus  for- 
maldehyde-gas may  be  made  for  the  purpose  of  disinfection  by  lighting 
a  large  alcohol-lamp  and  supporting  a  thin  sheet  of  iron  or  small  tin 
dish  over  and  in  contact  with  the  flame.  It  is  important  to  remember 
that  methylated  spirits  or  wood-alcohol  is  essential.) 

By  this  method  the  disinfectant  is  forced  deeply  into  and  per- 
meates the  interior  of  pillows  and  mattresses  and  other  articles  in  a  way 
that  has  proved  highly  efficient.  Experiments  made  in  the  pathological 
laboratory  have  demonstrated  that  the  ordinary  bacteria  are  killed  when 
placed  in  the  centre  of  a  mattress  or  pillow  thus  treated.  When  proper 
appliances  are  not  at  hand  for  an  exhaust-chamber,  the  measures  rec- 
ommended under  variola,  or  those  generally  given  out  by  boards  of 
health,  may  be  adopted,  as  the  following,  used  by  the  State  Board  of 
Health  of  New  Hampshire: — 

The  room  to  be  disinfected  is  sealed  and  prepared  as  for  sulphur 
disinfection.  All  surfaces  are  exposed  as  freely  as  possible;  closet  doors 
are  opened  and  their  contents,  together  with  the  contents  of  boxes, 
drawers,  etc.,  are  removed  and  spread  about,  the  drawers  and  boxes  to 
be  left  open;  mattresses  are  placed  on  end,  pillows,  bedding,  clothing, 
etc.,  are  suspended  from  lines  stretched  across  the  room  or  spread  out 
on  chairs  or  other  objects  so  as  to  afford  the  fullest  exposure,  and  books 
are  opened  and  the  leaves  separated.  In  short,  the  room  and  its  con- 
tents are  so  arranged  as  to  secure  free  access  of  the  gas  to  all  parts.  On 
this  depends  the  thoroughness  and  consequent  value  of  the  disinfec- 
tion. 

An  ordinary  bed-sheet  (2x2  1/2  yards,  or  2  x  2.5  metres)  is  then 
suspended  by  one  edge  from  a  line  stretched  across  the  middle  of  the 
room.  Properly  sprinkled,  this  will  carry  without  dripping  5  ounces 
(150  cubic  centimetres)  of  formalin, — the  40-per-cent.  solution  of  for- 
maldehyde,— which  is  sufficient  to  disinfect  1000  cubic  feet  (305  me- 
tres) of  space,  or  a  room  10  feet  (3  metres)  square.  As  many  sheets  as 
necessary  are  used,  hung  at  equal  distances  apart.  The  ordinary,  coarse, 
cotton  sheet  is  to  be  preferred,  as  it  facilitates  more  rapid  evaporation. 

The  sprinkling  is  done  by  means  of  a  spray-producer,  as  it  is 


382  THE    ACUTE    EXANTHEMATA. 

found  that  the  freest  evolution  of  the  gas  with  the  minimum  produc- 
tion of  paraform  is  secured  from  very  minute  drops  of  the  solution,  in- 
dividually scattered;  that  is,  not  touching  or  running  together,  on  the 
evaporating  surface. 

When  all  is  in  readiness  the  disinfector  ties  a  damp  towel  or 
sponge  over  his  mouth  and  nose,  and,  beginning  with  the  sheet  farthest 
from  the  door  of  exit,  rapidly  sprinkles  each  sheet  on  his  way  out, 
being  careful  to  spray  evenly  and  no  space  more  than  once. 

The  evolution  of  the  gas  is  so  rapid  that  the  air  becomes  irre- 
spirable  in  about  three  minutes,  so  that  quick  action  is  necessary.  It 
has  also  been  found  necessary  to  provide  the  operators  with  surgeon's 
rubber  gloves  to  protect  the  hands  and  wrists  from  the  spray. 

The  room  is  left  closed  not  more  than  five  hours,  after  which  it 
is  opened  up  as  freely  as  possible  to  sunlight  and  air;  the  family  is 
instructed  to  have  all  wood-work  well  scrubbed  with  soap  and  hot 
water  or  with  the  mercuric-chloride  solution,  and  the  furniture  and 
other  objects  thoroughly  wiped  with  cloths  moistened  with  dilute 
formalin  (1  part  of  formalin  to  20  parts  of  water). 

Disinfection  by  Heat.  —  The  experiments  of  Koch,  Gaffky,  and 
Loeffler  have  demonstrated  that  bacteria  are  killed  by  a  temperature 
of  320°  F.  (160°  C.).  Later,  Esmarch  and  Bunker  demonstrated  that 
when  moisture  was  added  a  temperature  of  from  212°  to  248°  F.  (100° 
to  120°  C.)  was  found  sufficient.  Heat  in  the  form  of  steam  is  there- 
fore used  in  disinfection.  A  chamber,  as  for  formaldehyde-gas,  is  pro- 
vided, and,  after  placing  the  articles  to  be  disinfected  therein,  the  air 
is  exhausted  until  a  vacuum  of  from  fifteen  to  twenty  atmospheres  is 
produced,  when  the  steam  is  allowed  to  enter.  In  this  way  permeation 
throughout  mattresses,  pillows,  and  quilts  is  assured.  A  strong  objec- 
tion to  disinfection  by  heat  arises  from  the  fact  that  it  injures  the 
fabric  of  many  articles,  and  when  moist  heat  or  steam  is  employed  it 
renders  the  interior  of  pillows  and  mattresses  damp.  Furthermore  it 
has  been  found  frequently  to  interfere  with  the  dye  of  cloth,  hair, 
wool,  etc.;  hence  it  is  less  serviceable  than  the  preceding  methods  of 
disinfection. 

Care  of  Rooms  in  Private  Du'ellimgs  during  the  Presence  of  an 
Infectious  Disease. — In  addition  to  what  has  been  said,  it  is  highly 
important  to  impress  on  the  minds  of  those  having  charge  of  the  sick- 
chamber  that  the  special  poison  of  the  disease  is  constantly  given  off 
from  the  patient,  and  that  to  allow  it  to  accumulate  within  a  close 
room  renders  its  infective  property  especially  active  and  thus  aug- 


ADDENDUM.  383 

ments  its  danger  to  others.  So  far,  therefore,  as  is  consistent  with 
the  welfare  of  the  patient,  the  room  throughout  the  whole  course  of 
the  illness  should  be  constantly  ventilated  and  frequently  aired.  It 
is  well  to  provide  a  means  of  disinfecting  the  foul  air  as  it  leaves  the 
room,  by  keeping  a  fire  burning  night  and  day  in  an  open  fire-place. 
Where  this  is  not  provided  an  open  stove  will  serve  the  same  purpose. 
It  is  likewise  well  to  keep  in  the  sick-room  a  vessel  containing  the  zinc 
solution  previously  mentioned,  for  the  reception  of  towels,  sheets,  and 
other  articles  of  clothing  which  are  not  to  be  burned  or  disinfected  in 
a  specially  prepared  oven. 

Hospitals  and  Wards  for  Infectious  Diseases. — As  a  means  of  pre- 
venting the  spread  of  infectious  diseases,  the  law  authorizes  the  inhab- 
itants of  cities,  villages,  and  townships  in  most  States  to  be  constantly 
provided  with  hospitals  for  the  reception  of  persons  having  small-pox, 
scarlet  fever,  measles,  or  any  other  disease  dangerous  to  the  public 
health.  In  case  no  provision  has  been  made  previous  to  an  outbreak 
of  any  such  disease,  the  law  directs  local  boards  of  health  to  provide 
proper  hospitals  or  places  of  reception  for  the  sick  and  infected  as  in 
their  judgment  seems  best  for  the  accommodation  of  the  afflicted  and 
the  safety  of  the  inhabitants.  It  is  further  incumbent  on  the  local 
health  authorities,  as  provided  by  law,  to  cause  all  persons  infected, 
or  supposed  to  be  infected  with  any  of  the  diseases  previously  men- 
tioned, to  be,  without  delay  (provided  their  condition  will  admit), 
conveyed  to  such  hospitals  or  places  of  reception. 

Hospital  Construction.— Since  the  erection  of  hospitals  is  some- 
times utilized  for  ulterior  or  selfish  ends,  rather  than  the  proper 
care  of  the  sick,  it  seems  incumbent  at  this  time  that  a  few  essen- 
tial features  of  a  general  nature  be  mentioned.  This  unfortunate 
condition  applies  more  especially  to  hospitals  which  fall  under  the 
moral  plague  of  American  cities  commonly  denominated  "politics." 
It  was  formerly  thought  that  hospitals  for  contagious  diseases  should 
be  placed  in  some  out-of-the-way  place,  remote  from  dwellings.  This 
opinion  still  prevails  among  the  laity,  and  strong  opposition  is  al- 
ways made  by  those  living  in  the  vicinity  of  a  proposed  hospital 
site.  Careful  observations  have  been  made,  however,  which  tend 
to  dispel  the  ground-work  of  this  popular  belief.  In  the  Boston 
City  Hospital  (loc.  tit.,  p.  7)  it  has  been  found  that  no  cases  of 
scarlet  fever  developed  within  the  one-eighth-of-a-mile  circle,  and 
fewer  cases  occurred  within  the  quarter-mile  circle  than  between  the 
three-fourths  and  the  mile  circles,  respectively  (see  page  230).  Our 


384  THE   ACUTE    EXANTHEMATA. 

experience  in  Cleveland  goes  to  prove  that,  when  properly  conducted, 
no  danger  may  be  feared  from  a  hospital  or  ward  which  is  completely 
shut  off  from  surrounding  buildings.  To  insure  this  safety  to  the 
territory  immediately  surrounding  the  hospital,  strict  quarantine  must 
be  maintained,  and  nurses,  orderlies,  and  resident  physicians  must 
not  be  allowed  to  come  in  contact  with  anyone  outside  the  hospital 
grounds.  It  has  been  repeatedly  demonstrated  that  air  and  the  sun's 
rays  are  potent  germ-destroyers,  but  that  various  contagia  adhere  to 
articles  such  as  clothing,  the  hair,  dishes  and  refuse  from  the  table, 
etc.,  and,  to  maintain  an  efficient  quarantine,  these  should  not  be 
allowed  to  leave  the  infected  area  until  after  disinfection.  Therefore 
a  disinfecting  appliance  and  a  crematory  for  disposing  of  garbage  are 
among  the  prerequisites  of  a  hospital  for  infectious  diseases.  Both  of 
these  should  be  near  at  hand  to  obviate  the  necessity  of  spreading  the 
infected  area.  The  more  simple  in  construction  the  better.  A  trap- 
door should  connect  directly  with  the  disinfecting  rooms  and  furnace; 
this  is  better  than  carrying  articles  from  one  room  to  another,  or  con- 
nection by  shafts  or  dumb-waiters.  During  an  epidemic  or  in  the 
country  these  may  be  extemporized. 

Sunlight,  ventilation,  and  heating  must  next  be  considered.  The 
importance  of  allowing  free  ingress  of  the  sun's  rays  when  desirable 
cannot  be  overestimated,  as  it  is  known  to  be  the  most  efficient  dis- 
infectant. It  is  also  desirable  to  allow  the  light  to  enter  from  all  sides 
of  the  room  if  possible. 

Ample  provision  for  ventilation  should  be  made.  When  other 
buildings  or  wards  are  in  close  proximity  to  the  infected  ward,  ven- 
tilation through  open  windows  and  doors  should  be  strictly  guarded 
against.  For  this  reason  it  is  better  to  have  them  constructed  so  that 
they  cannot  be  opened  in,  the  ordinary  way.  The  fresh  air  should  pass 
over  heated  coil  pipes  before  entering  the  room,  which  should  take 
place  at  different  elevations  to  insure  a  freer  admixture  than  when  the 
current  is  established  in  one  direction  only.  Thus,  when  two  flues  are 
sufficient,  as  in  a  small  room,  one  should  enter  within  two  feet  from 
the  floor,  and  the  other  about  two-thirds  of  the  wall  space  upward. 
The  aperture  for  the  exit  of  foul  air  should  be  placed  near  the  floor. 
The  foul-air  shaft  should  extend  without  angles  or  other  obstruction 
upward,  and  open  above  the  roof. 

When  stoves  are  used  to  heat  the  room  they  should  be  "jacketed," 
— that  is,  surrounded  by  a  sheet-iron  jacket;  and  the  inlet  of  fresh  air 
should  be  conducted  from  without  so  that  it  strikes  the  back  of  the 


ADDENDUM.  oS-J 

stove  inside  the  iron  sheeting.  The  foul  air  may  escape  either  through 
an  open  grate  in  which  fire  is  constantly  kept  or  in  a  flue  as  previously 
described. 

Ample  facilities  for  bathing  should  also  be  provided.  The  bath- 
room should  be  constructed  so  that  it  may  be  easily  cleaned  by  means 
of  a  hose  or  other  flushing.  The  floor  and  walls  are  best  made  of 
cement,  and  in  all  such  rooms  there  should  be  an  outside  window. 
Portable  bath-tubs  should  be  at  hand  for  patients  too  ill  to  go  to  the 
bath-room. 


INDEX. 


Addendum,  372. 

clothing,  dicinfection  of,  379. 
diagnosis,  differential  table  of,  374. 
disinfection,  formulary  for,  376. 
disinfection,  individual,  378. 
hospitals,  construction  of,  383. 
rooms,  fumigation  of,  379. 

Chicken-pox   (see  "Varicella"),  152 
Color,  influence  of,  14,  112,  236. 

Exanthemata,  the  acute,  early  history 

of,  1. 

in  America,  21. 
in  Arabia,  8. 
in  Caracas,  22. 
in  China,  1. 
in  Great  Britain,  15. 
in  Greece,  3. 
in  Iceland,  22. 
in  India,  2. 
in  Japan,  15. 
in  Mexico,  22. 
in  Naples,  23. 
in  Paris,  23. 
in  Rome,  4. 
in  Saxony,  24. 
in  Spain,  23. 
in  West  Indies,  21. 

Measles  (see  "Rubeola"),  276. 

Rubella,  348. 

definition  of,  348. 

synonyms  of,  348. 
complications  of,  361. 
diagnosis  of,  366. 

from  drug  eruptions,  370. 

from  measles,  366. 

from  scarlatina,  369. 

from  syphilis,  369. 
etiology  of,  363. 
pathology  of,  362. 
prognosis  of,  370. 
sequelae  of  (see  "Complications  of"), 

361. 
symptoms  of,  352. 

desqxiamation,  period  of,  360. 

eruption  in,  354. 

incubation  of,  352. 

invasion  of,  352. 

recognition  of,  early,  349. 

relapse  in,  362. 

temperature  in,  359. 
treatment  of,  370. 


Rubeola,  276. 

definition  of,  276. 

early  history  of,  9. 

synonyms  of,  276. 

varieties  of,  276. 
anomalous  forms,  288. 
ataxic  form,  292. 
eruption,  absence  of,  269. 
haemorrhagic  form,  292. 
malignant  form,  293. 
severe  form,  291. 
suffocative  form,  292. 
vulgaris,>  277. 

course  of,  277. 

desquamation,  stage  of,  287. 

enanthem  of,  279. 

eruption  in,  283. 

incubation,  period  of,  277. 

invasion  of,  277. 

mucous     membranes,     involve- 
ment of,  279. 

prodromal    stage,    duration    of, 
283. 

symptomatology,  277. 

symptoms,  catarrhal  of,  287. 

symptoms,  general  of.  279. 

temperature  in,  278,  285. 
complications  of,  294. 
bronchitis  in,  301. 
broncho-pneumonia  in,  302. 
diphtheria  in,  300. 
ears,  involvement  of,  297. 
eruption,  bullous  in,  295. 
eyes,  involvement  of,  297. 
furunculosis  in.  295. 
gangrene  in.  307. 

gastro-intestinal     tract,     involve- 
ment of.  302. 
heart  in,  306. 
impetigo  in,  295. 
Infectious      diseases,      co-existent 

with.  307. 

kidneys,  involvement  of,  306. 
larynx,  involvement  of.  299. 
lungs,  involvement  of.  300. 
mental  disorders  in,  306. 
mucous   membranes,    involvement 

of,  296. 
nervous   system,    invo'vement   of, 

303. 

phlebitis,  associated  with.  307. 
pregnancy,  associated  with,  308. 
purpura  in.  307. 
relapse  in,  290. 
respiratory  tract  in.  299. 
(387) 


388 


INDEX. 


Rubeola.  complications,  second  attacks 
of,  290. 

sequelae    of     (see    "Complications 
of"),  294. 

skin,  involvement  of,  294. 

tuberculosis  in.  295. 

urticaria  in,  296. 
diagnosis  of,  319. 

from  drug  eruptions,  321. 

from  erythema,  321. 

from  influenza,  319. 

from  rubella,  320. 

from  scarlatina,  320. 

from  syphilis,  324. 
etiology,  314. 

measles  in  lower  animals.  318. 

recurrence  of,  290. 
pathology  of,  308. 

bacteriology  of,  312. 

blood  in,  311. 

lungs,  involvement  of.  314. 

lymphatic  glands,  involvement  of, 
314. 

mucous   membranes,   involvement 
of,  308. 

skin,  involvement  of,  309. 
prognosis  of,  325. 
treatment  of,  330. 

antisepsis  in,  337. 

complications,  treatment  of,  342. 

convalescence  in,  347. 

diet  in,  340. 

eyes,  care  of,  338. 

hydrotherapy  in,  338,  342. 

laryngitis  in,  343. 

management  of,  335. 

nervous  system  in,  346. 

otitis  in,  treatment  of,  346. 

prophylaxis  in.  330. 

skin     and     mucous     membranes, 
management  of,  343. 

Scarlatina,  169. 

definition,  170. 

early  history  of,  /,  22. 

synonyms,  169. 

varieties,   170. 
irregular  forms,  186. 

laevigata,  187. 

laevis.  187. 

miliaris,  187. 

papulosa,  187. 

sine  angina,  189. 

sine  exanthemata,  186. 

*ino  febre,  188. 

variegata,  188. 
septic,  179. 
simple.  173. 
toxic.  183. 

advnamic  form.  184. 


Scarlatina,  toxic,  ataxic  form,  184. 

haemorrhagic  form,  185. 
complications  of,  190. 

abscess,  retropharyngeal,  in,  198. 

albuminuria  in;  201,  205. 

anasarca  in,  207. 

angina  gangraenosa  in,  192. 

angina  Ludovici  in,  197. 

angina  pseudomembranosa  in,  191. 

ankylosis  in,  200. 

arthritis  in,  199. 

bronchitis  in,  208. 

broncho-pneumonia  in,  208. 

cellulitis,  diffuse,  in,  196. 

conjunctivitis  in,  198,  210. 

convulsions  in,  207. 

cutaneous  affections  in,  212. 

cyanosis  in,  207. 

deafness,  acquired,  in,  195. 

delirium  in,  210. 

diarrhoea  in,  211. 

diphtheria  in,  193. 

eczema  in,  212. 

endocarditis  in,  208. 

eyes  in,  210. 

furunculosis  in,  212. 

gastro-intestinal  tract  in,  211. 

heart  in,  207. 

jaundice  in,  211. 

joints  in,  199. 

kidneys  in,  200. 

lymphatic  glands  in,  196,  198. 

mastoid  antrum,  empyema  of,  196. 

membrana    tympani,    rupture    of, 

195. 

nephritis,  frequency  of,  in,  203. 
nephritis  in,  201. 

nephritis,  influence  of.  age  in.  204. 
nervous  system  in,  209. 
noma  in.  211. 
oedema  in.  201,  205. 
otitis  in,  193. 
otitis,  svmptoms  of,  194. 
otorrhcea  in,   195. 
parotid  glands  in.  196. 
pericarditis  in.  208. 
phlebitis  in,  212. 

phlegmonous  inflammation  in.  197. 
photophobia  in,  210. 
pleurae  in,  209. 
pneumonia,  lobar,  in.  209. 
pulse  in.  205. 
rheumatism,    acute    articular,    in, 

199. 

skin  in.  212. 
spleen  in.  197. 
stomatitis  in,  211. 
synovitis  in.  199. 
throat  in,  190. 
tonsils  in,  191,  213. 


INDEX. 


389 


Scarlatina,  complications,  tuberculous 

infection  in,  200. 
uraemia  in,  206. 
urine  in,  201,  204,  205. 
urine,  suppression  of,  in,  207. 
vomiting  in,  205,  211. 
diagnosis  of,  244. 

cerebro-spinal  meningitis,  254. 

convulsions,  246. 

diphtheria,  251. 

drug  eruptions,  247. 

enanthem,  240. 

erysipelas,  250. 

erythema,  247. 

erythema  scarlatiniforme   desqua- 

mativum,  248. 
influenza,  253. 
lymphatic  glands,  250. 
measles,  251. 
rubella,  251. 
tonsillitis.  252. 
variola,  251. 
vomiting,  246. 
•    etiology  of,  225. 
age  in,  238. 
bacteriology  of,  225. 
climate  in,  227. 
contagiousness  of,  229. 
distribution  of,  227. 
epidemic  type  of,  243. 
immunity,  acquired,  in,  242. 
immunity,  personal,  237. 
infection,  the  scarlatinal,  by  what 

channels  absorbed,  231. 
infection,    the    scarlatinal,    when 

contagious,  235. 
predisposition  to,  the   individual, 

237. 

prevalence  of,  228. 
puerperal  scarlatina,  so  called,  241. 
social  conditions  in,  238. 
tenacity  of  poison,  235. 
transmission  of,  229,  233. 
wounds,    influence    of    accidental, 

in,  240. 

pathology  of,  215. 
blood  in,  224. 
bone-marrow  in.  224. 
desquamation  in,  217. 
endocarditis  in.  219. 
eruption  in,  215. 
gastro-intestinal  tract  in,  223. 
heart,  acute  hypertrophy,  in,  218. 
heart  in.  218. 
kidneys  in,  219. 
liver  in.  223. 

lymphatic  glands  in,  218. 
lymphatic  system  in,  217. 
myocarditis  in.  219. 
nephritis  in.  219. 


Scarlatina,  pathology,  pericarditis  in, 
219. 

peritoneum   in,   224. 

Peyer's  patches  in,  223. 

stomach  in,  223. 

tongue  in,  217. 
prognosis  of,  254. 

mortality  of.  255. 
sequelae  of,  213. 

aphasia  following,  214. 

arthritis  following.  214.- 

chorea  following,  214. 

encephalitis,  haemorrhagic,  follow- 
ing, 214. 

endocarditis  following,  214. 

glottis,  chronic  oedema  of,  follow- 
ing, 215. 

otorrhoea  following.  214. 

psychosis,  acute,  following,  215. 

torticollis  following,  214. 

tuberculosis,  infection  by,  follow- 
ing, 213. 
symptomatology  of,  170. 

actual  attack,  173. 

angina  of.  178. 

coma  in,  183,  185. 

convulsions  in,  174,  184. 

cough  in.  182. 

cutaneous  affections  in,  189. 

delirium  in,  181,   185. 

desquamation,  duration  of,  178. 

desquamation  in,  178. 

desquamation.  secondary,  in,  179. 

diarrhoea  in.  174,  184. 

dyspnoea  in.  184. 

eczema  in,  190. 

enanthem  in.  17(5. 

eruption  in.  176.  181,  184,  188. 

eruption,  duration  of,  188. 

exanthemata,  co-existence  of  other 
acute.  189. 

headache  in.  174 

heart  in,  182. 

incubation  of.  170. 

invasion  of.  173. 

lymphatic  jrlands  in,  174,  182. 

onset  of,  173. 

petechiae  in.  185. 

psoriasis  in.  190. 

pulse  in.  174.  182.  184. 

scabies  in.  190. 

skin  in,  178.  185. 

temperature  in.  174.  181. 

throat  in,  174.  178. 

tongue  in.  174.  178. 

tonsils  in.  174.  181. 

urine  in.  176.  181. 

vomiting  in.  174.  181.  185. 
treatment  of.  256 

anjrina.  266.  270 


390 


INDEX. 


Scarlatina,  treatment,  antistreptococcic 

serum  in,  265. 
arthritis,  274. 
cold  in,  267. 
complications,  270. 
diarrhoea,  275. 
diet  in,  264. 
diphtheria,  271. 
endocarditis,  274. 
fever,  management  of,  in,  267. 
gastro-enteritis,   275. 
hygiene,  general,  in,  263. 
hygiene,  personal,  in,  261. 
indications,  general,  in,  268. 
lymphatic  glands  in,  272. 
nephritis  in,  273. 
otitis,  272. 
pericarditis,  274. 
prophylaxis  in,  256. 
serum  in,  265. 
stomatitis,  275. 
throat,  266. 

Vaccinia,  128. 
abscesses  in,  139. 
anomalies  of,  132. 
antisepsis  in,  151. 
bacteriology  of,  130. 
complications  of,  135. 
definition  of,  129. 
eczema  in,  136. 
erysipelas  in,  138. 
erythema  in,  136. 
gangrene  in,  139. 
generalized,  134. 
glands,    lymphatic,   involvement   of 

132. 

haemorrhage  in,  138. 
history  of,  early,  128. 
hypertrophy,  papillary,  137. 
impetigo,  140. 
inoculation,  auto-,  of,  136. 
leprosy  in,  145. 

lymph,  bovine,  the  use  of    148 
practice  of,  150. 
psoriasis  in,  141. 
sequelae  of,  135. 
symptomatology  of,  131. 
syphilis  in,  142. 
tetanus  in,  139. 
tuberculosis  in,  141. 
ulceration  in,  139. 
vaccinia  and  variola,  common  source 

of.  130. 
virus,  selection  and  preservation  of 

147. 
Varicella,  152. 

definition  of.  152. 

history  of,  early.  11. 

synonyms  of,  l-52. 


Varicella,  varieties  of,  162. 

haemorrhagic  form,  162. 
complications  of,  161. 

nephritis,  acute,  162. 
diagnosis  of,  166. 

diagnosis,  early  confusion  of,  153. 
etiology  of,  164. 
history  of,  early,  18,  152. 

description  of,  first,  153. 
pathology  of,   163. 
prognosis  of,  167. 
sequelae  of,  161. 
symptomatology  of,  154. 
desquamation,  stage  of,  161. 
eruption,  evolution  of,  158. 
eruption,  stage  of,  157. 
incubation,  period  of,  154. 
prodromal  stage  of,  154. 
mucous   membranes,    involvement 

of,  160. 

symptoms,  subjective,  160. 
temperature  in,  156. 
treatment  of,  167. 
Variola,  28. 

definition  of,  28. 
synonyms  of,  28. 
varieties  of,  28. 

variola,  first  mention  of,  15,  16. 
confluent  form,  39. 
alopecia  in,  46. 
blindness  in,  46. 
collapse  in,  40. 
complications  in,  46. 
critical  period  of,  45. 
delirium  in,  44. 
desiccation,  stage  of.  45. 
diarrhoea  in,  43. 
eruption  in.  40. 
fever,  secondary  in,  43. 
invasion  of,  40. 
mucous  membranes,  involvement 

of.  41,  44. 
oedema  in.  43. 
pulse  in,  43. 
pyaemia  in,  46. 
salivation  in,  44. 
sleeplessness  in,  44. 
temperature  in,  40,  41. 
confluent,  semi-,  47. 
corymbose  form,  47. 
exudative  form,»52. 
haemorrhagic  forms,  48. 
haemorrhagic  pustular  form,  50. 
haemorrhage  in,  51. 
haemorrhages,  internal,  in,  52. 
invasion  of,  50. 
metrorrhagia  in,  52. 
mucous     membranes,      involve- 
ment of.  51. 
pregnancy,  influence  of,  52. 


INDEX. 


391 


Variola,   haemorrhagic  pustular   form, 

rash,  prodromal,  in,  51. 
recovery  in,  52. 
temperature  in,  51. 
inoculated  form,  60. 
irregular  form,  62. 

eruption,  course  of,  62. 
fever,  secondary,  in,  62. 
mildness  of,  62. 
stages,  duration  of.  62. 
purpuric  form,  48. 
delirium  in,  50. 
epidemic,  Dublin.  49. 
eruption,  prodromal,  in,  49. 
fatality  of,  50. 

influences  predisposing  to,  48. 
invasion  of,  49. 

mucous     membranes,     involve- 
ment of.  50. 
pulse  in,  49. 

sensory  disturbances  in.  50. 
temperature  in,  49. 
urine  in,  50. 
variola  modificata,  53. 
attacks,  abortive,  in,  56. 
attacks,  repeated,  of,  54. 
eruption  in,  57. 
fatality  of,  54. 
fever,  secondary,  in,  60. 
invasion  of,  56. 
mucous  membranes,  involvement 

of,  60. 

symptoms,  constitutional,  of,  60. 
temperature  in,  55.  61. 
vaccination,  effect  in,  53. 
variola  vera,  30. 

abscesses  in,  39. 

bronchitis  in,  33. 

bullae,  formation  of.  39. 

chills  in,  32. 

constipation  in,  32. 

convulsions  in,  33. 

crusts,  formation  of.  38. 

desiccation,  stage  of,  38. 

diarrhoea  in,  32. 

eruption,  induration  of.  37. 

eruption  of,  35. 

fever,  suppurative,  in,  38. 

furunculosis  in,  39. 

headache  in,  32. 

incubation  of,  31. 

invasion  of,  31. 

lesions,  size  of,  37. 

menstrual  flow  in,  32. 

mucous  membranes,  involvement 
of,  37. 

nerve-centres,    involvement    of, 
33. 

perspiration  in.  36. 

pregnancy  in.  32. 


Variola,  variola  vera,  pulse  in,  33. 
pus  cocci,  infection  by,  39. 
rash,  prodromal,  34. 
rash,  prodromal,  significance  of, 

35. 

respiration  in,  33. 
sleeplessness  in,  33. 
suppuration,  stage  of,  37. 
symptomatology  of,  30. 
temperature  in^  32. 
tongue  in,  32. 
umbilication  in,  37. 
urine  in,  34. 
varioloid,  53. 
complications  of,  62. 
ears,  65. 

abscesses,  cerebral,  following,  66. 
affections,  catarrhal,  of,  66. 
eyes,  64. 

abscesses  of,  64. 
cicatrices,  contraction  of,  64. 
conjunctivitis,  64. 
cornea,  destruction  of,  64. 
haemorrhages  into,  65. 
injuries,  permanent,  of,  64. 
suppuration,  extensive,  in,  65. 
ulceration  of,  64. 
joints,  affections  of,  69. 
lymphatics,  69. 

abscesses  of,  69. 
nervous  system,  66. 
ataxia,  68. 

disturbances,  functional,  of,  66. 
paraplegia  in,  67. 
sclerosis,  disseminated,  in,  69. 
thrombosis,  influence  of,  68. 
skin.  62. 

abscesses  of,  63. 
acne,  63. 
alopecia  in,   63. 
cicatrices  of,  63. 
gangrene  in,  63. 
pigmentation  in,  63. 
pus  organisms  in,  63. 
scratching,  influences  of,  63. 
sycosis,  63. 
viscera,  internal.  69. 

ovary,  inflammation  of,  69. 
testicle,  involvement  of,  69. 
diagnosis,  85. 
appendicitis,  87. 
cerebral  meningitis,  87. 
drug,  eruptions  of,  94. 
eczema,  94. 
impetigo,  89. 
influenza,  93. 
intussusception,  87. 
measles,  88. 
scarlet  fever,  89. 
syphilis,  93. 


392 


INDEX. 


Variola,    diagnosis,    toxic    substances, 

ingestinn  of,  88. 
varicella,  91. 
etiology,  78. 

age,  influence  of,  79. 
diseases  associated  with,  81. 
distribution,  aerial,  82. 
infection,  mode  of,  81. 
pregnancy,  influence  of,  80. 
race,  influence  of,  80. 
season  of  year,  influence  of,  79. 
sex,  influence  of,  80. 
pathology,  69. 

blood,  changes  in,  77. 
blood-vessels,  72. 
cells,  changes  in,  70. 
crust,  formation  of,  72. 
epithelial  changes  in,  72. 
exudation  in,  71. 
lesions  of,  seat  of,  70. 
micro-organisms  found  in,  74. 
mucous    membranes,    changes    in 

76. 

pigment,  formation  of.  72. 
scars,  formation  of,  72. 
serous  membranes,  changes  in,  77. 
tissue,  destruction  of,  72. 
umbilication.  71. 


Variola,    pathology,    viscera,    internal 

changes  in,  77. 
prognosis,  9«>. 

rash,  initial,  influence  of,  98. 
sequelae  (see  "Complications"),  62. 
treatment,  100. 

alcohol  in,  118. 

antisepsis,  influence  of,  121. 

bathing  in,   122. 

cold  in,  116. 

convulsions,  treatment  of,  124. 

diet  in,  117. 

disinfection  in,  108. 

enema  in,  120. 

eye,   125. 

fomentations,  hot,  in,  116. 

hygiene  in,  110. 

immunity,  duration  of,  103. 

light,  influence  of,  112. 

local  treatment  of,  120. 

mouth  and  nose,  treatment  of,  126. 

nursing  in.  111. 

prophylaxis  in,  100. 

quarantine  in.  100. 

vaccination,  101. 

vaccination,  royal  commission,  re- 
port of,  106. 


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